Medical Student Perceptions of Effective and Ineffective Educators during their Surgical Clerkship

Medical Student Perceptions of Effective and Ineffective Educators during their Surgical Clerkship | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Medical Student Perceptions of Effective and Ineffective Educators during their Surgical Clerkship Deanna Palenzuela Rothman, Alyssa Pradarelli, Emil Petrusa, Joy Moses, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4953859/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose While the operative experience is a core component of the surgical clerkship, studies have suggested interactions with strong teachers and mentors have the most significant impact on a student’s decision to pursue a surgical career. The goal of this study was to identify qualities of effective and ineffective educators from a medical student’s perspective and clarify successful educational techniques that can significantly impact medical students’ surgery clerkship experiences. Methods We conducted a qualitative analysis of all medical student Surgery clerkship evaluations of resident physicians and surgery faculty from 2018 to 2022 at four HMS affiliated tertiary care centers. We utilized grounded theory as a means of exploring and interpreting our data. Qualitative analysis was conducted with two reviewers per the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist guidelines for qualitative research. Results A total of 1,378 faculty evaluations were analyzed with a Cohen’s Kappa of 0.85, indicating excellent inter-rater reliability. The analysis revealed six key themes that resonated with medical students during surgical clerkships: Enabling Student Involvement, Investment in Student Learners, Positive Team Environment, High Yield Teaching, Clinical Role Models, and Personal Connection. Students valued educators who allowed independence, advocated for their involvement, and engaged with them both inside and outside the operating room. Effective educators prioritized educational experiences, set clear expectations, and provided feedback. They also shaped the team environment by including students and acknowledging their contributions. Successful teaching strategies included high-yield chalk-talks, multi-modal activities, and personalized topics. Students appreciated educators who demonstrated clinical excellence and sought personal connections, valuing mentorship and efforts to know them as individuals. Conclusions Surgical residents and attendings play a significant role in shaping the educational experience of medical students on the surgical clerkship. Based on our findings, we developed the “Surgical Educator’s Compass” to provide practical guidelines for educator interventions to incorporate varied teaching strategies, involve medical students, and maximize student education during the surgical clerkship. Medical Student Surgical Clerkship Surgical Education Resident Educator Surgical Faculty Figures Figure 1 Figure 2 Introduction The surgical clerkship is often a medical student’s first exposure to the surgical specialties and can have a significant impact on their perception and interest in surgery 1 – 5 . During the surgical clerkship, medical students are exposed to a variety of operations, surgical patient encounters, and team interactions with attendings and residents 3 . While the operative experience is a core component of the surgical clerkship, the interactions with good teachers and mentors typically have the most significant impact on a student’s decision to pursue a surgical field 6 – 11 . Medical students with more exposure to highly ranked resident teachers were more likely to pursue a career in surgery 7 . Similarly, students who identified working with good resident teachers not only had overall better clerkship scores but also expressed greater interest in a surgical specialty 8 . Analyses of student surveys and evaluations highlighted enthusiasm, positive attitude, active involvement with the student, clinical competence, and helpful feedback as some of the important qualities of effective teachers 9 – 16 . Overall, these studies emphasize the significant impact that educators can have on medical students’ perceptions and career choices. It is important to note that most of the existing literature on medical student teaching during surgical clerkships is based on survey data or teaching award comments, and therefore fail to capture which teaching approaches specifically are most effective for medical students 6 – 16 . This information is needed to train successful surgical educators and ensure that resident physicians and faculty are aware of not only which techniques they should be using, but also which ones to avoid. Therefore, there is a need to delineate actionable teaching strategies that are identified by medical students and can be successfully implemented by resident physicians and attending surgeons. The goal of this study was to identify what medical students perceive as qualities of effective and ineffective educators based on student evaluations during the general surgery clerkship. Methods Surgical Clerkship Structure Upon entering Harvard Medical School (HMS), students are randomly placed into one of three HMS-affiliated tertiary care centers for their main clinical clerkships. Additionally, a group of 10–15 students opt into the HMS-Cambridge Integrated Clerkship, offering a continuous longitudinal clerkship model at a community hospital affiliated with HMS. Following 14 months of pre-clinical foundational courses, students embark on a year of clinical rotations at their assigned hospitals. The surgical clerkship lasts three months and includes a four-week rotation in either General Surgery or Trauma, a week each in anesthesia and the intensive care unit, two weeks in the emergency department, and a final four weeks dedicated to elective rotations. These electives are chosen by the students and cover a range of surgical specialties including Orthopaedics, Plastic Surgery, Ophthalmology, Otolaryngology, and Neurosurgery. The curriculum during the surgical clerkship also features weekly educational sessions and simulations led by a team of faculty, fellows, resident physicians, and senior medical students. At the end of their surgical rotation, students are required to evaluate the resident and attending physicians with whom they had significant interactions. Student Resident and Faculty Evaluation Data Collection We conducted a qualitative analysis of medical student Surgery clerkship evaluations of resident physicians and surgery faculty from 2018 to 2022 at four HMS affiliated tertiary care centers. Evaluations of anesthesia residents and faculty were excluded. IRB approval was obtained from the Mass General Brigham (MGB) IRB as well as permissions from the HMS Academy Research Group and HMS Surgery Education Committee. All evaluation data was anonymized using an honest data broker (EP). Qualitative Analysis We utilized grounded theory as a means of exploring and interpreting our data. Qualitative analysis was conducted with two reviewers per the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist guidelines for qualitative research 16 . Coding was performed by DP and AP, with Dedoose (SCRC, Los Angeles, CA) as our code management software. Both reviewers were General Surgery resident physicians and Massachusetts General Hospital (MGH) Surgery Education Research Fellows who were experienced in performing qualitative surgical education research. Before and during data analysis, both coders considered how their personal contexts as surgical residents and surgical education researchers might affect their interpretation of the data. DP and AP independently reviewed the first 200 faculty evaluations, focusing on identifying educator qualities that impacted the student experience, and developed preliminary codes. Next, the coders independently continued reviewing evaluations until no new codes emerged, suggesting they had reached saturation. Upon completion of independent coding, DP and AP collaborated to unify their codebooks and then coded all of the evaluations. The two coders then cooperatively developed categories and, later, themes from these codes. Results A total of 1,378 faculty evaluations were collected. Inter-rater reliability testing resulted in a Cohen’s Kappa of 0.85, indicating an excellent level of reliability. Twenty-three codes were consistently present throughout the data within six clear themes representing educator qualities and teaching techniques that resonated with medical students during their surgical clerkships: Enabling Student Involvement, Investment in Student Learners, Positive Team Environment, High Yield Teaching, Clinical Role Models, and Personal Connection (Table 1 ). These themes are organized based on the frequency of the codes they represent, with the themes containing more frequent codes discussed first and with the least frequent codes last. An overview of the relative code frequencies can be found in Fig. 1 . Quotes included in the results are transcribed as written in the student evaluations. Given the anonymization of the data, student responses are not credited to specific student evaluations. Table 1 Data Themes, Codes, and Corresponding Definitions Theme Codes Definition Enabling Student Involvement Independence Students appreciate when the educator gives them the autonomy to act and think independently, and do not appreciate when educators do not provide this opportunity. Engagement Educator invites student to participate in skills practice, direct patient care, hands on learning experiences, and the OR. Advocate Advocates for student to be involved in patient care. Preparation Aids the student in preparing for their rotation (ie. OR cases, patient care, clinic, etc). Investment in Student Learners Feedback Educator provides frequent, constructive, actionable feedback. Expectation Setting Strong educators set clear expectations for the rotation and the student's role on the team. Challenging Challenges the student to improve within a supportive environment. Prioritization of Education Carves out time or adds time to the work day for teaching regardless of the busyness or stress of the service. Positive Team Environment Team Inclusion The educator facilitates integration of the student into the surgical team and makes them feel welcome in the surgical environment. Psychological Safety The educator creates a safe environment where the student feels comfortable approaching them, making mistakes, and asking questions. Clear Communication Communicates clearly with the student and whole team regarding daily tasks and expectations. Positive Attitude Educator is described as enthusiastic and having a positive attitude towards teaching, as well as toward their job in general. Also includes when the student describes a negative attitude as a detriment. Value Acknowledgement Recognizes the value the student adds to the team, and expresses gratitude. High Yield Teaching Meaningful Teaching Educator provides teaching on high yield topics or skills to prepare students for the surgery clerkship. Avoids non-educational tasks. Personalized Teaching Elicits goals from the students and tailors educational experiences toward student's goals and/or interests. Multi-modal Teaching Utilizes different forms of teaching, including formal didactics/lectures, in-the-moment instruction or discussion, literature investigation, etc. Questions Uses questions to probe fund of knowledge and prompt further learning. Clinical Role Models Clinical Excellence Student describes the educator as modeling excellence for patient care and in the OR. Professionalism Students appreciate when educators model professionalism toward the team and their patients, and are disappointed when unprofessional behaviors are modeled. Thought Process Provides insight and explanations to the decision-making and critical thinking that is needed when providing patient care. Personal Connection Personal Investment Sees the student as a whole person, takes the time to get to know them personally. Mentorship Student describes the educator as providing career advice or guidance. Theme #1: Enabling Student Involvement Students most frequently commented on how effective educators encouraged and enabled them to be hands-on in their learning. To set the student up for success, the best resident and attending educators would help them prepare for their operative experiences (See Appendix 1:1a for specific quote). Most importantly, for some students, the unique environment of the operating room (OR) can be particularly intimidating. With the educator’s guidance, students can feel more confident and comfortable in the OR, therefore maximizing their educational experience. Resident educators in particular also acted as advocates to encourage student involvement in patient care. Their position as leaders of the inpatient team can be used to empower student engagement (see Appendix 1:1b). Excellent educators advocated for their student by encouraging them to be involved in the operation, guiding them as to the right time to scrub in, and checking in to make sure they were comfortable. This kind of investment in the student’s educational experience is very impactful to students’ perception of learning and acceptance on the surgical clerkship. Additionally, the best educators allowed the students an appropriate level of autonomy. These experiences included independently seeing patients, presenting histories, working on notes, or assisting with procedures (see Appendix 1:1c). When educators trusted students to act independently, the students eagerly rose to the occasion and the opportunities to practice the skills they had observed were valued as great educational experiences. Correspondingly, students were especially discouraged by residents or attendings who did not make an effort to engage them. As mentioned previously, students sought opportunities to help the team and act independently, but to do so often required the encouragement from their educator. Unfortunately, not all students had educators who welcomed their involvement (see Appendix 1:1d). When students described neglect, it was consistently a similar experience of feeling like an outsider, not encouraged to participate in the day-to-day activities of the team. Therefore, when residents or attendings showed disinterest, students similarly became disinterested and disheartened. Theme #2: Investment in Student Learners By taking small steps to ensure their students were set up for success, faculty left students with the impression that they were genuinely invested in their educational experience. The strongest educators would start the student’s rotation by delineating expectations for their role on the team (see Appendix 1:2a). Often, these students did not have previous exposure to surgery, so setting these guidelines helped them feel better prepared to take on their surgical rotations. Additionally, eliciting the student’s personal goals helped align their interests with the educator’s objectives. As the student continued on the service, these expectations were best maintained by providing regular feedback. Students often commented on how honest, actionable feedback would inspire them to improve (see Appendix 1:2b). Students sought feedback from their educators, however, not all faculty provided appropriate feedback. As noted in the previous quote, good feedback was constructive, specific, and gave the student the opportunity to improve and build upon what they had learned. Students often noted when faculty would either not provide feedback or provided ineffective feedback: (see Appendix 1:2c). Students saw feedback as an opportunity for growth, so being deprived of that opportunity was particularly disheartening. When educators gave clear expectations and feedback on their progress, students were motivated to push themselves as learners (see Appendix 1:2d). By challenging their students to succeed, educators showed investment in their students’ growth, which in turn led the students to believe in their own potential. In addition, one of the most impactful ways educators demonstrated investment in the students was by prioritizing their education. Students recognized that the clinical day was often busy, which made the moments faculty took time to teach particularly meaningful (see Appendix 1:2e). Therefore, teaching does not always have to be structured, but rather small teaching moments throughout the day maximized the student’s educational experience. On the other hand, the most common complaint was when educators would not make this effort (see Appendix 1:2f). Similar comments were common throughout the evaluations, and highlight how much students valued when teaching is prioritized. It is important to note that students often recognize that busy days are not always conducive to teaching, and therefore the strongest educators were those who found a way to incorporate student learning into those demanding clinical schedules. Theme #3: Positive Team Environment The team dynamic is one of the most unique aspects of surgical culture, and students viewed surgical educators as responsible for setting the tone of that environment. There were several ways students mentioned their faculty would positively contribute to the environment. First, and most commonly noted, was establishing a psychologically safe environment. The strongest educators allowed the students to feel comfortable and confident asking questions and sharing their curiosity. This was important of both resident and attending physicians. Residents often would set the tone outside of the OR. (see Appendix 1:3a). On the other hand, students saw the role of the attending as directing the atmosphere inside of the OR during cases (see Appendix 1:3b). In both instances, students appreciated being able to learn in an environment where they were encouraged to ask questions, and could be wrong without repercussions. The safe space allowed their curiosity and interest in surgery to grow. Similarly, students greatly valued when their resident physicians would make them feel “like a welcome part of the team”. Resident educators would do so by involving them in tasks, and by acknowledging them as a valuable addition to the team’s productivity. Additionally, attending educators would welcome students into the operating room, and interact with them during cases. Actively involving students as team members inspired them to be more engaged and proactive when contributing to patient care but likely requires dedicated pre-clinical instruction to maximize each student’s knowledge and effectiveness. Another important aspect of the team dynamic is effective communication. Students often noted that strong educators were able to lead their team by clearly delegating roles and tasks to each member (see Appendix 1:3c). For students, this effective communication helped define their role within the team and therefore allowed them to maximally contribute and learn. In general, the team environment was significantly impacted by the overall attitude of the surgical educator. Residents and attending educators with positive attitudes towards teaching inspired similar excitement in the students they taught (see Appendix 1:3d). However, the opposite was also true; negative attitudes were toxic to the team dynamic (see Appendix 1:3e). Students reflected the attitudes put forth by their educators in that positive leaders similarly led to enthusiastic students, while negative outlooks would cloud the student’s surgical experience. Theme #4: High Yield Teaching There were several different teaching strategies that students noted effective educators employed. First was providing what felt like meaningful teaching. Students would commend when educators provided practical or “high yield” teaching points on topics relevant to the cases they would see that day or would need to know for their exams (see Appendix 1:4a). In doing so, students felt that the educator’s time and their time were being used effectively to focus on only the most pertinent surgical knowledge to understand. Similarly, students appreciated when teaching was personalized to their interests or needs. Educators effectively elicited those interests by asking students if there were any particular topics they were hoping to learn or experience early in the rotation (see Appendix 1:4b). By tailoring teaching to the student’s preferences, the educator showed interest in the student as an individual. This approach has the benefit of helping students feel engaged and personally connected to them as individuals. Within the OR, students felt the best educators would teach using focused questions. This use of teaching scripts was the most common way students noted they would have the opportunity to interact with attendings. Questioning in the OR would help keep students engaged, focus their learning, and clarify areas where they could continue to grow (see Appendix 1:4c). Since the OR was the most common environment where students interacted with attendings, active Socratic questioning sessions were also one of a students’ few opportunities to highlight their medical knowledge and technical skills. Therefore, the use of standardized questioning scripts by attending surgeons also allowed fair student assessments and constructive feedback opportunities. Another often commented-on technique was using multi-modal teachings strategies. In other words, rather than only relying on chalk talks or intra-operative teaching alone, strong educators would use a variety of teaching strategies and techniques (see Appendix 1:4e). These teaching strategies helped keep student learners engaged and interested in varying settings. This method was a particularly effective way that educators could incorporate teaching moments within a busy clinical schedule. Theme #5: Clinical Role Models This theme highlights how medical students turn to faculty to exemplify clinical acumen and skill. Students frequently noted when educators personified clinical excellence, both inside and outside of the OR. Intra-operatively, students were attuned to the technical skills attendings and resident physicians demonstrated (see Appendix 1: 5a). Specifically, students often appreciated when educators would share their thought process around different clinical situations, and many saw this as significantly contributing to their learning. In particular, students noted when educators would not explain the “why” when making clinical decisions, and frequently gave this as constructive feedback for educator improvement (see Appendix 1:5b). Students valued when educators provide glimpses into their surgical decision-making so they could similarly begin to develop those skills themselves. The medical students noted that a surgical educator displayed clinical excellence not only through technical skills and knowledge, but also through their interactions with peers, patients, and the students themselves (see Appendix 1:5c). Teacher behaviors such as showing respect, kindness, and professionalism towards everyone, truly distinguished a role model in the eyes of medical students. Such a view emphasizes how these students look to surgical educators to learn not only technical skills and medical knowledge, but also how to behave as a surgeon. Theme #6: Personal Connection Residents and attendings that made an effort to establish personal connections with the students were greatly valued. Educators showed interest in the student as a person by eliciting their goals within medicine, discussing their hobbies outside of the hospital, and assuaging their fears or anxieties about surgery (see Appendix 1:6a). In getting to know the students personally, educators could also tailor their teaching towards the student’s interests and goals to maximize their learning. On the other hand, although infrequent, students were particularly offput when their resident or attending made no effort to connect with them (see Appendix 1:6b). This indifference from the faculty not only led to the student’s diminished interest in that particular rotation, but also in the field of surgery as a whole. At times, residents and attendings would go beyond their roles as teachers to become mentors (see Appendix 1:6c). Students who found mentors among their educators often cited this connection as leading to their own decisions to pursue a career in surgery (see Appendix 1:6d). Excellent educators passed on their knowledge freely, inspiring medical students to follow in a similar path. Discussion Medical students’ resident physician and faculty evaluations revealed many characteristics of effective and ineffective surgical educators. Although there were some differences in the educational roles of residents and attendings, the student evaluations revealed successful educational techniques that all educators should utilize to significantly impact medical students’ surgery clerkship experiences. Residents versus Attending Educators Attending surgeons and resident physicians have significant roles in the students’ experiences, however, they appear to have slightly different educational domains. For example, medical students perceived residents as having the largest impact on day-to-day clinical activities, patient care, and inpatient team dynamic. Since students spent most of their time with their resident educators, the majority of the dedicated educational time was often a responsibility of the resident. This finding is supported by prior studies that similarly reported students see residents as their primary source of patient care education 18 . Additionally, residents had the largest influence on incorporating the student into the surgical team and providing them opportunities to be involved in patient care. As suggested by existing literature 9 – 16 , the strongest resident educators were those who recognized their unique position and empowered students to be engaged, grow, and succeed. On the other hand, students viewed the attending surgeons as leading the educational experience in the OR. A prior study conducted by Schwind and colleagues investigating the medical student experience in the OR specifically similarly found that the learning environment was most significantly influenced by the attending’s tone, teaching ability, and amount of interaction with the student 19 . Our findings add additional insight into how attendings specifically impact the operative environment as educators. Importantly, OR team members likely see the OR as a working environment whereas students see the OR as a learning environment. Therefore, attending surgeons may require additional training to help create a psychologically safe environment in the OR to allow the student to feel comfortable and welcome. This training would likely benefit all learners in the OR including resident physicians, nurse trainees, and anesthesia residents or CRNA trainees. Similarly, attending surgeons could likely benefit from training in the use of Socratic questioning in the OR to bring out the best engagement in both medical students and resident physicians. One possible solution is the use of standardized teaching scripts which are prepared teaching topics or questions for particular cases or situations. Utilizing prepared teaching scripts can help minimize the cognitive load of engaging the medical student for surgical educators. Our results highlight that both resident physicians and attending surgeons have significant roles in the educational experience of medical students. Further, our students recognized both residents and attendings provided meaningful mentorship during the clerkship and beyond. As prior studies have noted, identifying residents and attendings as role models not only improves the student’s clerkship experience, but also increases the likelihood they pursue a career in surgery themselves 19 , 20 . Ineffective Educators When students identified ineffective educators, there was one prevailing theme they all had in common: they failed to engage the medical student. This lack of engagement presented in a variety of ways, including not taking time for teaching moments, providing feedback, interacting with them in the OR, or giving students opportunities to be involved in patient care. There are likely many possible reasons for essentially ignoring students as investing in medical student education takes time, and the increased time demand and lack of teaching compensation on top of a clinically demanding schedule are clear barriers to surgical educators 21 , 22 . The Surgical Educator’s Compass We have summarized the findings of this study into a “Surgical Educator’s Compass” which is illustrated in Fig. 2 . Like an actual compass, the goal of this tool is to guide surgical educators through the phases of medical student learning. These tips are designed to require minimal time commitment from the educator, while maximizing the student’s educational experience based on the results of this study. Before working with medical students, academic institutions should provide resident and attending faculty development opportunities to educate them on effective teaching and feedback strategies. If not provided by their institution, motivated educators should seek educational resources to be knowledgeable and prepared for student teaching. Some examples of educational courses and resources can be found in the American College of Surgeons and Association for Surgical Education websites 24 – 26 . Before the start of the clerkship, clerkship leadership should organize student orientation to involve basic surgical skill practice, such as knot tying and suturing, to help students feel confident and prepared before going into the OR. This preparation has the added benefit of giving the educators a foundation on which to continue to help guide the student’s technical skill development. At the start of the surgical clerkship, an effective surgical educator should establish a safe space for curiosity. Educators can establish a psychologically safe environment by encouraging questions and responding with positivity and patience. This is the first step in the toolkit purposefully; by establishing a safe space, students will be more receptive to the educational tips that follow. A psychologically safe environment is what will make the difference between engagement and mistreatment 27 – 29 . Similarly, educators should recognize students as members of the team. Simply acknowledging the student’s role in the inpatient team, and particularly noting their value to the team’s efficacy, can make a significant difference in the student’s perception of belonging. Lastly, educators should begin rotations by setting clear expectations. Appropriate expectations can include the student’s rounding responsibilities, role in caring for floor patients, and expected preparation for the OR. Taking time at the start of the rotation to delineate the medical student’s roles and responsibilities has the benefit of aligning the expectations of the educator with the goals of the student. Throughout the surgical clerkship, the surgical educator should provide regular, actionable constructive feedback. Setting aside time at least once in the middle of the rotation to provide feedback on the student’s performance helps the student feel that the educator is invested in their education and growth. Ideal feedback should be immediate, actionable, based on observed behaviors, and include both positive observations, and areas for improvement 30 , 31 . Ideally, surgical educators should make time for short teaching points. Students noted and appreciated when the educator made an effort to incorporate teaching moments throughout the day. This practice could take varying forms and varying amounts of time, from chalk talks, to suturing skills practice, to surgical decision-making explanations during rounds, or anatomy reviews before entering the OR. As described above, surgeons in particular should take the time to prepare questions for the operating room. Having a set of questions prepared to ask the student throughout the operation can help keep the student interested and highlight the educational takeaways from the case. Resident education leaders should take the time to designate independent student tasks. Some examples of appropriate student tasks include interviewing patients, assisting with clinical notes, or assisting with procedures they have observed, such as placing NG tubes, pulling drains, or suturing. Allowing student autonomy in patient care can benefit the teams as a whole, and is often a highlight of their surgical clerkship experience. Lastly, both attending surgeons and resident physicians should try to get to know the student as a person. Asking the student about their medical interests, clinical experiences so far, and hobbies can go a long way. By eliciting the student’s goals and interests, both inside and outside of the hospital, a genuine connection can be formed between the medical student and educator, potentially leading to a mentoring relationship. Following the student’s clerkship experience, these mentorships can continue to grow, leading to meaningful, long-term connections. Medical student relationships may also persist even if the student does not pursue a surgical career and the student may eventually become a surgeon’s referring provider or consultant. Lastly, as a component of continued faculty development, educators should be given the opportunity to regularly review their student’s evaluations. By reflecting on the student’s feedback, attendings and residents can themselves continue to refine their teaching strategies and grow as effective educators. Limitations There are limitations to this study. First, the evaluations were originally organized in alphabetical order prior to anonymization, and the coders both independently agreed they had reached saturation in the data after reading through approximately 2/3rds of the evaluation. Therefore, there is a possibility that new codes could have emerged in the later alphabetical faculty’s evaluations. However, saturation had been reached for over 100 evaluations prior to discontinuing coding, making this bias unlikely. The main limitation is this study was based on evaluation data from students from a single medical school, therefore limiting the generalizability of our findings. However, many of our main themes were supported by existing literature, suggesting our results are likely applicable to medical student experiences at other institutions. Lastly, while our results highlight lack of engagement as a defining quality of ineffective educators, it fails to capture the motivations behind these behaviors. As mentioned earlier, we hypothesize that time and compensation are two key barriers to engaging medical students. However, future investigations should aim to identify what factors lead to the differences in educators’ interests in work with medical students. Conclusion Surgical residents and attendings play a significant role in shaping the educational experience of medical students on the surgical clerkship. Based on our findings, we developed the “Surgical Educator’s Compass” to provide practical guidelines for educator interventions to incorporate varied teaching strategies, involve medical students, and maximize student education during the surgical clerkship. By enabling more residents and attendings to become effective educators, we in turn can inspire a new generation of medical students about the rewards and challenges associated with a surgical career and a surgeon’s important patient care role in modern medical practice. Abbreviations Harvard Medical School (HMS) ; Mass General Brigham (MGB); Operating Room (OR) Declarations Data Availability Statement: The data that support the findings of this study are available from Harvard Medical School, however, given that the data contained identifiable information about the students and educators, the data is not available to the public. References McKinley, Sophia K., et al. "Enhancing the formal preclinical curriculum to improve medical student perception of surgery." Journal of surgical education 77.4 (2020): 788-798. Marshall, Dominic C., et al. "Medical student experience in surgery influences their career choices: a systematic review of the literature." Journal of surgical education 72.3 (2015): 438-445. Patel, Madhukar S., et al. "Early intervention to promote medical student interest in surgery and the surgical subspecialties." Journal of Surgical Education 70.1 (2013): 81-86. Cortez, Alexander R., et al. "Predictors of medical student success on the surgery clerkship." The American Journal of Surgery 217.1 (2019): 169-174. Al-Heeti, Khalaf NM, et al. "The effect of general surgery clerkship rotation on the attitude of medical students towards general surgery as a future career." Journal of surgical education 69.4 (2012): 544-549. Morgan, Helen K., et al. "Student evaluation of faculty physicians: gender differences in teaching evaluations." Journal of Women's Health 25.5 (2016): 453-456. Musunuru, Sandeepa, et al. "Effective surgical residents strongly influence medical students to pursue surgical careers." Journal of the American College of Surgeons 204.1 (2007): 164-167. Whittaker Jr, Lorin D., et al. "The value of resident teaching to improve student perceptions of surgery clerkships and surgical career choices." The American journal of surgery 191.3 (2006): 320-324. Ehrlich, Peter F., and P. A. Seidman. "Deconstructing surgical education–teacher quality really matters: implications for attracting medical students to surgical careers." The American Surgeon 72.5 (2006): 430-434. Quillin III, Ralph C., et al. "Surgeons underestimate their influence on medical students entering surgery." journal of surgical research 177.2 (2012): 201-206. Lamb CR, Guerra S, Sorensen MJ. Qualities of excellent resident and attending teachers recognized by medical students: A qualitative analysis of nominations for surgical clerkship teaching awards. The American Journal of Surgery. 2022 Jul 1;224(1):552-6. Garner, Matthew S., Richard J. Gusberg, and Anthony W. Kim. "The positive effect of immediate feedback on medical student education during the surgical clerkship." Journal of Surgical Education 71.3 (2014): 391-397. Arah OA, Heineman MJ, Lombarts KMJMH. Factors influencing post-graduate trainees’ evaluations of clinical faculty member teaching qualities and role model status. Med Educ 2012;46:381–389. Irby D, Rakestraw P. Evaluating clinical teaching in medicine. J Med Educ 1981;56:181–186. Irby DM, Ramsey PG, Gillmore GM, Schaad D. Characteristics of effective clinical teachers. Acad Med 1991;66: 54–55. Mullan P, Sullivan D, Dielman T. What are raters rating? Predicting medical student, pediatric post-graduate trainee, and faculty ratings of clinical teachers. Teach Learn Med 1993;5:221–226. Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care , 19 (6), 349-357. De SK, Henke PK, Ailawadi G, Dimick JB, Colletti LM. Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship. Journal of the American College of Surgeons. 2004 Dec 1;199(6):932-42. Schwind CJ, Boehler ML, Rogers DA, Williams RG, Dunnington G, Folse R, Markwell SJ. Variables influencing medical student learning in the operating room. The American journal of surgery. 2004 Feb 1;187(2):198-200. Berman L, Rosenthal MS, Curry LA, Evans LV, Gusberg RJ. Attracting surgical clerks to surgical careers: role models, mentoring, and engagement in the operating room. Journal of the American College of Surgeons. 2008 Dec 1;207(6):793-800. Acton RD, Chipman JG, Lunden M, Schmitz CC. Unanticipated teaching demands rise with simulation training: strategies for managing faculty workload. Journal of surgical education. 2015 May 1;72(3):522-9. Zahn CM, Dunlow SG, Alvero R, Parker JD, Nace MC, Armstrong AY. Too little time to teach? Medical student education and the resident work-hour restriction. Military medicine. 2007 Oct 1;172(10):1053-7. Castillo-Angeles M, Calvillo-Ortiz R, Barrows C, Chaikof EL, Kent TS. The learning environment in surgery clerkship: what are faculty perceptions?. Journal of Surgical Education. 2020 Jan 1;77(1):61-8. American College of Surgeons. ACS Residents as Teachers and Leaders. American College of Surgeons. [updated: 2024; cited: 2024 April 15]. Available from: https://www.facs.org/for-medical-professionals/education/programs/acs-residents-as-teachers-and-leaders/ American College of Surgeons. ACS Surgeons as Educators. American College of Surgeons. [updated: 2024; cited: 2024 April 15]. Available from: https://www.facs.org/for-medical-professionals/education/programs/acs-surgeons-as-educators/ Association for Surgical Education. Educational Resources. Association for Surgical Education. [updated: 2024; cited: 2024 April 15]. Available from: https://www.surgicaleducation.com/educational-clearinghouse/ Arad D, Finkelstein A. Patient safety and staff psychological safety: a mixed methods study on aspects of teamwork in the operating room. Frontiers in public health. 2022 Dec 23;10:1060473. McClintock AH, Fainstad TL, Jauregui J. Clinician teacher as leader: creating psychological safety in the clinical learning environment for medical students. Academic medicine. 2022 Nov 1;97(11S):S46-53. Chrouser KL, Partin MR. Intraoperative disruptive behavior: the medical student's perspective. Journal of surgical education. 2019 Sep 1;76(5):1231-40. Garner MS, Gusberg RJ, Kim AW. The positive effect of immediate feedback on medical student education during the surgical clerkship. Journal of Surgical Education. 2014 May 1;71(3):391-7. Perera J, Lee N, Win K, Perera J, Wijesuriya L. Formative feedback to students: the mismatch between faculty perceptions and student expectations. Medical teacher. 2008 Jan 1;30(4):395-9. Supplementary Files Appendix.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 10 Mar, 2025 Reviewers invited by journal 15 Oct, 2024 Editor invited by journal 02 Oct, 2024 Editor assigned by journal 04 Sep, 2024 First submitted to journal 26 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4953859","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":366297651,"identity":"ea377ca9-b338-414d-b4e3-40c454516248","order_by":0,"name":"Deanna Palenzuela Rothman","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0008-4657-5164","institution":"Massachusetts General Hospital Department of Surgery","correspondingAuthor":true,"prefix":"","firstName":"Deanna","middleName":"Palenzuela","lastName":"Rothman","suffix":""},{"id":366297652,"identity":"8cb4475c-5cc5-4d31-bf6b-fa20f3d30972","order_by":1,"name":"Alyssa Pradarelli","email":"","orcid":"","institution":"University of Michigan Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Alyssa","middleName":"","lastName":"Pradarelli","suffix":""},{"id":366297653,"identity":"d3f59945-3d59-4806-b4ad-e3e5c4cadfc8","order_by":2,"name":"Emil Petrusa","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Emil","middleName":"","lastName":"Petrusa","suffix":""},{"id":366297654,"identity":"061ebebf-0ce8-4ae8-a3f8-d62372146e08","order_by":3,"name":"Joy Moses","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Joy","middleName":"","lastName":"Moses","suffix":""},{"id":366297655,"identity":"94cee55c-eaff-4a43-9b7e-3439db5281d3","order_by":4,"name":"Roy Phitayakorn","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Roy","middleName":"","lastName":"Phitayakorn","suffix":""}],"badges":[],"createdAt":"2024-08-21 20:46:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4953859/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4953859/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67293028,"identity":"d9afccf5-dc0d-42dd-aeb2-a2afd1399ec2","added_by":"auto","created_at":"2024-10-23 10:33:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":304538,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003eRelative Code Frequencies within the Surgical Clerkship Faculty Evaluation Data\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis figure illustrates the relative frequency of our codes and themes throughout the medical student evaluations. Codes that were more prevalent in the data were interpreted to reflect increased relevance and importance to the medical students.\u003c/p\u003e","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4953859/v1/e9efa05603d5b21da10407c1.jpg"},{"id":67293026,"identity":"c1a5e6bf-0bf3-43d2-aa0c-d02664ca776c","added_by":"auto","created_at":"2024-10-23 10:33:05","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":179617,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003eThe Surgical Educator’s Compass\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe Surgical Educator’s Compass is designed to guide the educator through the different phases of medical student education. The guidelines illustrated are encouraged for all educators to utilize during before, during, and after the surgical clerkship.\u003c/p\u003e","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4953859/v1/cd27fddd8dc354f47528b1fb.jpg"},{"id":67294053,"identity":"a2393ca9-356f-4539-baa4-2ab238b2beba","added_by":"auto","created_at":"2024-10-23 10:41:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":950931,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4953859/v1/32a704b3-0130-4c3e-8d5b-5f770ff8836f.pdf"},{"id":67294035,"identity":"48587c59-dc2b-4736-a9f7-f57c793eaec2","added_by":"auto","created_at":"2024-10-23 10:41:05","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25481,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-4953859/v1/169b9414a8d66f8a6bb6c0e3.docx"}],"financialInterests":"","formattedTitle":"Medical Student Perceptions of Effective and Ineffective Educators during their Surgical Clerkship","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe surgical clerkship is often a medical student\u0026rsquo;s first exposure to the surgical specialties and can have a significant impact on their perception and interest in surgery\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. During the surgical clerkship, medical students are exposed to a variety of operations, surgical patient encounters, and team interactions with attendings and residents\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. While the operative experience is a core component of the surgical clerkship, the interactions with good teachers and mentors typically have the most significant impact on a student\u0026rsquo;s decision to pursue a surgical field\u003csup\u003e\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Medical students with more exposure to highly ranked resident teachers were more likely to pursue a career in surgery\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Similarly, students who identified working with good resident teachers not only had overall better clerkship scores but also expressed greater interest in a surgical specialty\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Analyses of student surveys and evaluations highlighted enthusiasm, positive attitude, active involvement with the student, clinical competence, and helpful feedback as some of the important qualities of effective teachers\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Overall, these studies emphasize the significant impact that educators can have on medical students\u0026rsquo; perceptions and career choices.\u003c/p\u003e \u003cp\u003eIt is important to note that most of the existing literature on medical student teaching during surgical clerkships is based on survey data or teaching award comments, and therefore fail to capture which teaching approaches specifically are most effective for medical students\u003csup\u003e\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. This information is needed to train successful surgical educators and ensure that resident physicians and faculty are aware of not only which techniques they should be using, but also which ones to avoid. Therefore, there is a need to delineate actionable teaching strategies that are identified by medical students and can be successfully implemented by resident physicians and attending surgeons. The goal of this study was to identify what medical students perceive as qualities of effective and ineffective educators based on student evaluations during the general surgery clerkship.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical Clerkship Structure\u003c/h2\u003e \u003cp\u003eUpon entering Harvard Medical School (HMS), students are randomly placed into one of three HMS-affiliated tertiary care centers for their main clinical clerkships. Additionally, a group of 10\u0026ndash;15 students opt into the HMS-Cambridge Integrated Clerkship, offering a continuous longitudinal clerkship model at a community hospital affiliated with HMS. Following 14 months of pre-clinical foundational courses, students embark on a year of clinical rotations at their assigned hospitals. The surgical clerkship lasts three months and includes a four-week rotation in either General Surgery or Trauma, a week each in anesthesia and the intensive care unit, two weeks in the emergency department, and a final four weeks dedicated to elective rotations. These electives are chosen by the students and cover a range of surgical specialties including Orthopaedics, Plastic Surgery, Ophthalmology, Otolaryngology, and Neurosurgery. The curriculum during the surgical clerkship also features weekly educational sessions and simulations led by a team of faculty, fellows, resident physicians, and senior medical students. At the end of their surgical rotation, students are required to evaluate the resident and attending physicians with whom they had significant interactions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudent Resident and Faculty Evaluation Data Collection\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative analysis of medical student Surgery clerkship evaluations of resident physicians and surgery faculty from 2018 to 2022 at four HMS affiliated tertiary care centers. Evaluations of anesthesia residents and faculty were excluded. IRB approval was obtained from the Mass General Brigham (MGB) IRB as well as permissions from the HMS Academy Research Group and HMS Surgery Education Committee. All evaluation data was anonymized using an honest data broker (EP).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Analysis\u003c/h2\u003e \u003cp\u003eWe utilized grounded theory as a means of exploring and interpreting our data. Qualitative analysis was conducted with two reviewers per the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist guidelines for qualitative research\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Coding was performed by DP and AP, with Dedoose (SCRC, Los Angeles, CA) as our code management software. Both reviewers were General Surgery resident physicians and Massachusetts General Hospital (MGH) Surgery Education Research Fellows who were experienced in performing qualitative surgical education research. Before and during data analysis, both coders considered how their personal contexts as surgical residents and surgical education researchers might affect their interpretation of the data.\u003c/p\u003e \u003cp\u003eDP and AP independently reviewed the first 200 faculty evaluations, focusing on identifying educator qualities that impacted the student experience, and developed preliminary codes. Next, the coders independently continued reviewing evaluations until no new codes emerged, suggesting they had reached saturation. Upon completion of independent coding, DP and AP collaborated to unify their codebooks and then coded all of the evaluations. The two coders then cooperatively developed categories and, later, themes from these codes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1,378 faculty evaluations were collected. Inter-rater reliability testing resulted in a Cohen\u0026rsquo;s Kappa of 0.85, indicating an excellent level of reliability. Twenty-three codes were consistently present throughout the data within six clear themes representing educator qualities and teaching techniques that resonated with medical students during their surgical clerkships: Enabling Student Involvement, Investment in Student Learners, Positive Team Environment, High Yield Teaching, Clinical Role Models, and Personal Connection (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). These themes are organized based on the frequency of the codes they represent, with the themes containing more frequent codes discussed first and with the least frequent codes last. An overview of the relative code frequencies can be found in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Quotes included in the results are transcribed as written in the student evaluations. Given the anonymization of the data, student responses are not credited to specific student evaluations.\u0026nbsp;\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eData Themes, Codes, and Corresponding Definitions\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTheme\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCodes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDefinition\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eEnabling Student Involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIndependence\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents appreciate when the educator gives them the autonomy to act and think independently, and do not appreciate when educators do not provide this opportunity.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eEngagement\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducator invites student to participate in skills practice, direct patient care, hands on learning experiences, and the OR.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAdvocate\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdvocates for student to be involved in patient care.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePreparation\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAids the student in preparing for their rotation (ie. OR cases, patient care, clinic, etc).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eInvestment in Student Learners\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eFeedback\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducator provides frequent, constructive, actionable feedback.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eExpectation Setting\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStrong educators set clear expectations for the rotation and the student\u0026apos;s role on the team.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eChallenging\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChallenges the student to improve within a supportive environment.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePrioritization of Education\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCarves out time or adds time to the work day for teaching regardless of the busyness or stress of the service.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003ePositive Team Environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eTeam Inclusion\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe educator facilitates integration of the student into the surgical team and makes them feel welcome in the surgical environment.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePsychological Safety\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe educator creates a safe environment where the student feels comfortable approaching them, making mistakes, and asking questions.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eClear Communication\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommunicates clearly with the student and whole team regarding daily tasks and expectations.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePositive Attitude\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducator is described as enthusiastic and having a positive attitude towards teaching, as well as toward their job in general. Also includes when the student describes a negative attitude as a detriment.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eValue Acknowledgement\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRecognizes the value the student adds to the team, and expresses gratitude.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eHigh Yield Teaching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMeaningful Teaching\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEducator provides teaching on high yield topics or skills to prepare students for the surgery clerkship. Avoids non-educational tasks.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePersonalized Teaching\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eElicits goals from the students and tailors educational experiences toward student\u0026apos;s goals and/or interests.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMulti-modal Teaching\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUtilizes different forms of teaching, including formal didactics/lectures, in-the-moment instruction or discussion, literature investigation, etc.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eQuestions\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUses questions to probe fund of knowledge and prompt further learning.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eClinical Role Models\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eClinical Excellence\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudent describes the educator as modeling excellence for patient care and in the OR.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eProfessionalism\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudents appreciate when educators model professionalism toward the team and their patients, and are disappointed when unprofessional behaviors are modeled.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eThought Process\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProvides insight and explanations to the decision-making and critical thinking that is needed when providing patient care.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003ePersonal Connection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ePersonal Investment\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSees the student as a whole person, takes the time to get to know them personally.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMentorship\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStudent describes the educator as providing career advice or guidance.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ch2\u003eTheme #1: Enabling Student Involvement\u003c/h2\u003e\n\u003cp\u003eStudents most frequently commented on how effective educators encouraged and enabled them to be hands-on in their learning. To set the student up for success, the best resident and attending educators would help them prepare for their operative experiences (See \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:1a for specific quote). Most importantly, for some students, the unique environment of the operating room (OR) can be particularly intimidating. With the educator\u0026rsquo;s guidance, students can feel more confident and comfortable in the OR, therefore maximizing their educational experience.\u003c/p\u003e\n\u003cp\u003eResident educators in particular also acted as advocates to encourage student involvement in patient care. Their position as leaders of the inpatient team can be used to empower student engagement (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:1b). Excellent educators advocated for their student by encouraging them to be involved in the operation, guiding them as to the right time to scrub in, and checking in to make sure they were comfortable. This kind of investment in the student\u0026rsquo;s educational experience is very impactful to students\u0026rsquo; perception of learning and acceptance on the surgical clerkship.\u003c/p\u003e\n\u003cp\u003eAdditionally, the best educators allowed the students an appropriate level of autonomy. These experiences included independently seeing patients, presenting histories, working on notes, or assisting with procedures (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:1c). When educators trusted students to act independently, the students eagerly rose to the occasion and the opportunities to practice the skills they had observed were valued as great educational experiences.\u003c/p\u003e\n\u003cp\u003eCorrespondingly, students were especially discouraged by residents or attendings who did not make an effort to engage them. As mentioned previously, students sought opportunities to help the team and act independently, but to do so often required the encouragement from their educator. Unfortunately, not all students had educators who welcomed their involvement (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:1d). When students described neglect, it was consistently a similar experience of feeling like an outsider, not encouraged to participate in the day-to-day activities of the team. Therefore, when residents or attendings showed disinterest, students similarly became disinterested and disheartened.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme #2: Investment in Student Learners\u003c/h2\u003e\n \u003cp\u003eBy taking small steps to ensure their students were set up for success, faculty left students with the impression that they were genuinely invested in their educational experience. The strongest educators would start the student\u0026rsquo;s rotation by delineating expectations for their role on the team (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:2a). Often, these students did not have previous exposure to surgery, so setting these guidelines helped them feel better prepared to take on their surgical rotations. Additionally, eliciting the student\u0026rsquo;s personal goals helped align their interests with the educator\u0026rsquo;s objectives.\u003c/p\u003e\n \u003cp\u003eAs the student continued on the service, these expectations were best maintained by providing regular feedback. Students often commented on how honest, actionable feedback would inspire them to improve (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:2b). Students sought feedback from their educators, however, not all faculty provided appropriate feedback. As noted in the previous quote, good feedback was constructive, specific, and gave the student the opportunity to improve and build upon what they had learned. Students often noted when faculty would either not provide feedback or provided ineffective feedback: (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:2c). Students saw feedback as an opportunity for growth, so being deprived of that opportunity was particularly disheartening. When educators gave clear expectations and feedback on their progress, students were motivated to push themselves as learners (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:2d). By challenging their students to succeed, educators showed investment in their students\u0026rsquo; growth, which in turn led the students to believe in their own potential.\u003c/p\u003e\n \u003cp\u003eIn addition, one of the most impactful ways educators demonstrated investment in the students was by prioritizing their education. Students recognized that the clinical day was often busy, which made the moments faculty took time to teach particularly meaningful (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:2e). Therefore, teaching does not always have to be structured, but rather small teaching moments throughout the day maximized the student\u0026rsquo;s educational experience. On the other hand, the most common complaint was when educators would not make this effort (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:2f). Similar comments were common throughout the evaluations, and highlight how much students valued when teaching is prioritized. It is important to note that students often recognize that busy days are not always conducive to teaching, and therefore the strongest educators were those who found a way to incorporate student learning into those demanding clinical schedules.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme #3: Positive Team Environment\u003c/h2\u003e\n \u003cp\u003eThe team dynamic is one of the most unique aspects of surgical culture, and students viewed surgical educators as responsible for setting the tone of that environment. There were several ways students mentioned their faculty would positively contribute to the environment. First, and most commonly noted, was establishing a psychologically safe environment. The strongest educators allowed the students to feel comfortable and confident asking questions and sharing their curiosity. This was important of both resident and attending physicians. Residents often would set the tone outside of the OR. (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:3a). On the other hand, students saw the role of the attending as directing the atmosphere inside of the OR during cases (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:3b). In both instances, students appreciated being able to learn in an environment where they were encouraged to ask questions, and could be wrong without repercussions. The safe space allowed their curiosity and interest in surgery to grow.\u003c/p\u003e\n \u003cp\u003eSimilarly, students greatly valued when their resident physicians would make them feel \u0026ldquo;like a welcome part of the team\u0026rdquo;. Resident educators would do so by involving them in tasks, and by acknowledging them as a valuable addition to the team\u0026rsquo;s productivity. Additionally, attending educators would welcome students into the operating room, and interact with them during cases. Actively involving students as team members inspired them to be more engaged and proactive when contributing to patient care but likely requires dedicated pre-clinical instruction to maximize each student\u0026rsquo;s knowledge and effectiveness.\u003c/p\u003e\n \u003cp\u003eAnother important aspect of the team dynamic is effective communication. Students often noted that strong educators were able to lead their team by clearly delegating roles and tasks to each member (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:3c). For students, this effective communication helped define their role within the team and therefore allowed them to maximally contribute and learn.\u003c/p\u003e\n \u003cp\u003eIn general, the team environment was significantly impacted by the overall attitude of the surgical educator. Residents and attending educators with positive attitudes towards teaching inspired similar excitement in the students they taught (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:3d). However, the opposite was also true; negative attitudes were toxic to the team dynamic (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:3e). Students reflected the attitudes put forth by their educators in that positive leaders similarly led to enthusiastic students, while negative outlooks would cloud the student\u0026rsquo;s surgical experience.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme #4: High Yield Teaching\u003c/h2\u003e\n \u003cp\u003eThere were several different teaching strategies that students noted effective educators employed. First was providing what felt like meaningful teaching. Students would commend when educators provided practical or \u0026ldquo;high yield\u0026rdquo; teaching points on topics relevant to the cases they would see that day or would need to know for their exams (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:4a). In doing so, students felt that the educator\u0026rsquo;s time and their time were being used effectively to focus on only the most pertinent surgical knowledge to understand.\u003c/p\u003e\n \u003cp\u003eSimilarly, students appreciated when teaching was personalized to their interests or needs. Educators effectively elicited those interests by asking students if there were any particular topics they were hoping to learn or experience early in the rotation (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:4b). By tailoring teaching to the student\u0026rsquo;s preferences, the educator showed interest in the student as an individual. This approach has the benefit of helping students feel engaged and personally connected to them as individuals.\u003c/p\u003e\n \u003cp\u003eWithin the OR, students felt the best educators would teach using focused questions. This use of teaching scripts was the most common way students noted they would have the opportunity to interact with attendings. Questioning in the OR would help keep students engaged, focus their learning, and clarify areas where they could continue to grow (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:4c). Since the OR was the most common environment where students interacted with attendings, active Socratic questioning sessions were also one of a students\u0026rsquo; few opportunities to highlight their medical knowledge and technical skills. Therefore, the use of standardized questioning scripts by attending surgeons also allowed fair student assessments and constructive feedback opportunities.\u003c/p\u003e\n \u003cp\u003eAnother often commented-on technique was using multi-modal teachings strategies. In other words, rather than only relying on chalk talks or intra-operative teaching alone, strong educators would use a variety of teaching strategies and techniques (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:4e). These teaching strategies helped keep student learners engaged and interested in varying settings. This method was a particularly effective way that educators could incorporate teaching moments within a busy clinical schedule.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme #5: Clinical Role Models\u003c/h2\u003e\n \u003cp\u003eThis theme highlights how medical students turn to faculty to exemplify clinical acumen and skill. Students frequently noted when educators personified clinical excellence, both inside and outside of the OR. Intra-operatively, students were attuned to the technical skills attendings and resident physicians demonstrated (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1: 5a). Specifically, students often appreciated when educators would share their thought process around different clinical situations, and many saw this as significantly contributing to their learning. In particular, students noted when educators would not explain the \u0026ldquo;why\u0026rdquo; when making clinical decisions, and frequently gave this as constructive feedback for educator improvement (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:5b). Students valued when educators provide glimpses into their surgical decision-making so they could similarly begin to develop those skills themselves.\u003c/p\u003e\n \u003cp\u003eThe medical students noted that a surgical educator displayed clinical excellence not only through technical skills and knowledge, but also through their interactions with peers, patients, and the students themselves (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:5c). Teacher behaviors such as showing respect, kindness, and professionalism towards everyone, truly distinguished a role model in the eyes of medical students. Such a view emphasizes how these students look to surgical educators to learn not only technical skills and medical knowledge, but also how to behave as a surgeon.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eTheme #6: Personal Connection\u003c/h2\u003e\n \u003cp\u003eResidents and attendings that made an effort to establish personal connections with the students were greatly valued. Educators showed interest in the student as a person by eliciting their goals within medicine, discussing their hobbies outside of the hospital, and assuaging their fears or anxieties about surgery (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:6a). In getting to know the students personally, educators could also tailor their teaching towards the student\u0026rsquo;s interests and goals to maximize their learning. On the other hand, although infrequent, students were particularly offput when their resident or attending made no effort to connect with them (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:6b). This indifference from the faculty not only led to the student\u0026rsquo;s diminished interest in that particular rotation, but also in the field of surgery as a whole.\u003c/p\u003e\n \u003cp\u003eAt times, residents and attendings would go beyond their roles as teachers to become mentors (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:6c). Students who found mentors among their educators often cited this connection as leading to their own decisions to pursue a career in surgery (see \u003cspan class=\"InternalRef\"\u003eAppendix\u003c/span\u003e 1:6d). Excellent educators passed on their knowledge freely, inspiring medical students to follow in a similar path.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eMedical students\u0026rsquo; resident physician and faculty evaluations revealed many characteristics of effective and ineffective surgical educators. Although there were some differences in the educational roles of residents and attendings, the student evaluations revealed successful educational techniques that all educators should utilize to significantly impact medical students\u0026rsquo; surgery clerkship experiences.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eResidents versus Attending Educators\u003c/h2\u003e \u003cp\u003eAttending surgeons and resident physicians have significant roles in the students\u0026rsquo; experiences, however, they appear to have slightly different educational domains. For example, medical students perceived residents as having the largest impact on day-to-day clinical activities, patient care, and inpatient team dynamic. Since students spent most of their time with their resident educators, the majority of the dedicated educational time was often a responsibility of the resident. This finding is supported by prior studies that similarly reported students see residents as their primary source of patient care education\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Additionally, residents had the largest influence on incorporating the student into the surgical team and providing them opportunities to be involved in patient care. As suggested by existing literature\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, the strongest resident educators were those who recognized their unique position and empowered students to be engaged, grow, and succeed.\u003c/p\u003e \u003cp\u003eOn the other hand, students viewed the attending surgeons as leading the educational experience in the OR. A prior study conducted by Schwind and colleagues investigating the medical student experience in the OR specifically similarly found that the learning environment was most significantly influenced by the attending\u0026rsquo;s tone, teaching ability, and amount of interaction with the student\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Our findings add additional insight into how attendings specifically impact the operative environment as educators. Importantly, OR team members likely see the OR as a working environment whereas students see the OR as a learning environment. Therefore, attending surgeons may require additional training to help create a psychologically safe environment in the OR to allow the student to feel comfortable and welcome. This training would likely benefit all learners in the OR including resident physicians, nurse trainees, and anesthesia residents or CRNA trainees. Similarly, attending surgeons could likely benefit from training in the use of Socratic questioning in the OR to bring out the best engagement in both medical students and resident physicians. One possible solution is the use of standardized teaching scripts which are prepared teaching topics or questions for particular cases or situations. Utilizing prepared teaching scripts can help minimize the cognitive load of engaging the medical student for surgical educators.\u003c/p\u003e \u003cp\u003eOur results highlight that both resident physicians and attending surgeons have significant roles in the educational experience of medical students. Further, our students recognized both residents and attendings provided meaningful mentorship during the clerkship and beyond. As prior studies have noted, identifying residents and attendings as role models not only improves the student\u0026rsquo;s clerkship experience, but also increases the likelihood they pursue a career in surgery themselves\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eIneffective Educators\u003c/h2\u003e \u003cp\u003eWhen students identified ineffective educators, there was one prevailing theme they all had in common: they failed to engage the medical student. This lack of engagement presented in a variety of ways, including not taking time for teaching moments, providing feedback, interacting with them in the OR, or giving students opportunities to be involved in patient care. There are likely many possible reasons for essentially ignoring students as investing in medical student education takes time, and the increased time demand and lack of teaching compensation on top of a clinically demanding schedule are clear barriers to surgical educators\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eThe Surgical Educator\u0026rsquo;s Compass\u003c/h2\u003e \u003cp\u003eWe have summarized the findings of this study into a \u0026ldquo;Surgical Educator\u0026rsquo;s Compass\u0026rdquo; which is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Like an actual compass, the goal of this tool is to guide surgical educators through the phases of medical student learning. These tips are designed to require minimal time commitment from the educator, while maximizing the student\u0026rsquo;s educational experience based on the results of this study.\u003c/p\u003e \u003cp\u003eBefore working with medical students, academic institutions should provide resident and attending faculty development opportunities to educate them on effective teaching and feedback strategies. If not provided by their institution, motivated educators should seek educational resources to be knowledgeable and prepared for student teaching. Some examples of educational courses and resources can be found in the American College of Surgeons and Association for Surgical Education websites\u003csup\u003e\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Before the start of the clerkship, clerkship leadership should organize student orientation to involve basic surgical skill practice, such as knot tying and suturing, to help students feel confident and prepared before going into the OR. This preparation has the added benefit of giving the educators a foundation on which to continue to help guide the student\u0026rsquo;s technical skill development.\u003c/p\u003e \u003cp\u003eAt the start of the surgical clerkship, an effective surgical educator should establish a safe space for curiosity. Educators can establish a psychologically safe environment by encouraging questions and responding with positivity and patience. This is the first step in the toolkit purposefully; by establishing a safe space, students will be more receptive to the educational tips that follow. A psychologically safe environment is what will make the difference between engagement and mistreatment\u003csup\u003e\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Similarly, educators should recognize students as members of the team. Simply acknowledging the student\u0026rsquo;s role in the inpatient team, and particularly noting their value to the team\u0026rsquo;s efficacy, can make a significant difference in the student\u0026rsquo;s perception of belonging. Lastly, educators should begin rotations by setting clear expectations. Appropriate expectations can include the student\u0026rsquo;s rounding responsibilities, role in caring for floor patients, and expected preparation for the OR. Taking time at the start of the rotation to delineate the medical student\u0026rsquo;s roles and responsibilities has the benefit of aligning the expectations of the educator with the goals of the student.\u003c/p\u003e \u003cp\u003eThroughout the surgical clerkship, the surgical educator should provide regular, actionable constructive feedback. Setting aside time at least once in the middle of the rotation to provide feedback on the student\u0026rsquo;s performance helps the student feel that the educator is invested in their education and growth. Ideal feedback should be immediate, actionable, based on observed behaviors, and include both positive observations, and areas for improvement\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Ideally, surgical educators should make time for short teaching points. Students noted and appreciated when the educator made an effort to incorporate teaching moments throughout the day. This practice could take varying forms and varying amounts of time, from chalk talks, to suturing skills practice, to surgical decision-making explanations during rounds, or anatomy reviews before entering the OR. As described above, surgeons in particular should take the time to prepare questions for the operating room. Having a set of questions prepared to ask the student throughout the operation can help keep the student interested and highlight the educational takeaways from the case. Resident education leaders should take the time to designate independent student tasks. Some examples of appropriate student tasks include interviewing patients, assisting with clinical notes, or assisting with procedures they have observed, such as placing NG tubes, pulling drains, or suturing. Allowing student autonomy in patient care can benefit the teams as a whole, and is often a highlight of their surgical clerkship experience. Lastly, both attending surgeons and resident physicians should try to get to know the student as a person. Asking the student about their medical interests, clinical experiences so far, and hobbies can go a long way. By eliciting the student\u0026rsquo;s goals and interests, both inside and outside of the hospital, a genuine connection can be formed between the medical student and educator, potentially leading to a mentoring relationship.\u003c/p\u003e \u003cp\u003eFollowing the student\u0026rsquo;s clerkship experience, these mentorships can continue to grow, leading to meaningful, long-term connections. Medical student relationships may also persist even if the student does not pursue a surgical career and the student may eventually become a surgeon\u0026rsquo;s referring provider or consultant. Lastly, as a component of continued faculty development, educators should be given the opportunity to regularly review their student\u0026rsquo;s evaluations. By reflecting on the student\u0026rsquo;s feedback, attendings and residents can themselves continue to refine their teaching strategies and grow as effective educators.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThere are limitations to this study. First, the evaluations were originally organized in alphabetical order prior to anonymization, and the coders both independently agreed they had reached saturation in the data after reading through approximately 2/3rds of the evaluation. Therefore, there is a possibility that new codes could have emerged in the later alphabetical faculty\u0026rsquo;s evaluations. However, saturation had been reached for over 100 evaluations prior to discontinuing coding, making this bias unlikely. The main limitation is this study was based on evaluation data from students from a single medical school, therefore limiting the generalizability of our findings. However, many of our main themes were supported by existing literature, suggesting our results are likely applicable to medical student experiences at other institutions. Lastly, while our results highlight lack of engagement as a defining quality of ineffective educators, it fails to capture the motivations behind these behaviors. As mentioned earlier, we hypothesize that time and compensation are two key barriers to engaging medical students. However, future investigations should aim to identify what factors lead to the differences in educators\u0026rsquo; interests in work with medical students.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSurgical residents and attendings play a significant role in shaping the educational experience of medical students on the surgical clerkship. Based on our findings, we developed the \u0026ldquo;Surgical Educator\u0026rsquo;s Compass\u0026rdquo; to provide practical guidelines for educator interventions to incorporate varied teaching strategies, involve medical students, and maximize student education during the surgical clerkship. By enabling more residents and attendings to become effective educators, we in turn can inspire a new generation of medical students about the rewards and challenges associated with a surgical career and a surgeon\u0026rsquo;s important patient care role in modern medical practice.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eHarvard Medical School (HMS) ; Mass General Brigham (MGB); Operating Room (OR)\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from Harvard Medical School, however, given that the data contained identifiable information about the students and educators, the data is not available to the public. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMcKinley, Sophia K., et al. \u0026quot;Enhancing the formal preclinical curriculum to improve medical student perception of surgery.\u0026quot; \u003cem\u003eJournal of surgical education\u003c/em\u003e 77.4 (2020): 788-798.\u003c/li\u003e\n\u003cli\u003eMarshall, Dominic C., et al. \u0026quot;Medical student experience in surgery influences their career choices: a systematic review of the literature.\u0026quot; \u003cem\u003eJournal of surgical education\u003c/em\u003e 72.3 (2015): 438-445.\u003c/li\u003e\n\u003cli\u003ePatel, Madhukar S., et al. \u0026quot;Early intervention to promote medical student interest in surgery and the surgical subspecialties.\u0026quot; \u003cem\u003eJournal of Surgical Education\u003c/em\u003e 70.1 (2013): 81-86.\u003c/li\u003e\n\u003cli\u003eCortez, Alexander R., et al. \u0026quot;Predictors of medical student success on the surgery clerkship.\u0026quot; \u003cem\u003eThe American Journal of Surgery\u003c/em\u003e 217.1 (2019): 169-174.\u003c/li\u003e\n\u003cli\u003eAl-Heeti, Khalaf NM, et al. \u0026quot;The effect of general surgery clerkship rotation on the attitude of medical students towards general surgery as a future career.\u0026quot; \u003cem\u003eJournal of surgical education\u003c/em\u003e 69.4 (2012): 544-549.\u003c/li\u003e\n\u003cli\u003eMorgan, Helen K., et al. \u0026quot;Student evaluation of faculty physicians: gender differences in teaching evaluations.\u0026quot; \u003cem\u003eJournal of Women\u0026apos;s Health\u003c/em\u003e 25.5 (2016): 453-456.\u003c/li\u003e\n\u003cli\u003eMusunuru, Sandeepa, et al. \u0026quot;Effective surgical residents strongly influence medical students to pursue surgical careers.\u0026quot; \u003cem\u003eJournal of the American College of Surgeons\u003c/em\u003e 204.1 (2007): 164-167.\u003c/li\u003e\n\u003cli\u003eWhittaker Jr, Lorin D., et al. \u0026quot;The value of resident teaching to improve student perceptions of surgery clerkships and surgical career choices.\u0026quot; \u003cem\u003eThe American journal of surgery\u003c/em\u003e 191.3 (2006): 320-324.\u003c/li\u003e\n\u003cli\u003eEhrlich, Peter F., and P. A. Seidman. \u0026quot;Deconstructing surgical education\u0026ndash;teacher quality really matters: implications for attracting medical students to surgical careers.\u0026quot; \u003cem\u003eThe American Surgeon\u003c/em\u003e 72.5 (2006): 430-434.\u003c/li\u003e\n\u003cli\u003eQuillin III, Ralph C., et al. \u0026quot;Surgeons underestimate their influence on medical students entering surgery.\u0026quot; \u003cem\u003ejournal of surgical research\u003c/em\u003e 177.2 (2012): 201-206.\u003c/li\u003e\n\u003cli\u003eLamb CR, Guerra S, Sorensen MJ. Qualities of excellent resident and attending teachers recognized by medical students: A qualitative analysis of nominations for surgical clerkship teaching awards. The American Journal of Surgery. 2022 Jul 1;224(1):552-6.\u003c/li\u003e\n\u003cli\u003eGarner, Matthew S., Richard J. Gusberg, and Anthony W. Kim. \u0026quot;The positive effect of immediate feedback on medical student education during the surgical clerkship.\u0026quot; \u003cem\u003eJournal of Surgical Education\u003c/em\u003e 71.3 (2014): 391-397.\u003c/li\u003e\n\u003cli\u003eArah OA, Heineman MJ, Lombarts KMJMH. Factors influencing post-graduate trainees\u0026rsquo; evaluations of clinical faculty member teaching qualities and role model status. Med Educ 2012;46:381\u0026ndash;389. \u003c/li\u003e\n\u003cli\u003eIrby D, Rakestraw P. Evaluating clinical teaching in medicine. J Med Educ 1981;56:181\u0026ndash;186. \u003c/li\u003e\n\u003cli\u003eIrby DM, Ramsey PG, Gillmore GM, Schaad D. Characteristics of effective clinical teachers. Acad Med 1991;66: 54\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eMullan P, Sullivan D, Dielman T. What are raters rating? Predicting medical student, pediatric post-graduate trainee, and faculty ratings of clinical teachers. Teach Learn Med 1993;5:221\u0026ndash;226.\u003c/li\u003e\n\u003cli\u003eTong, A., Sainsbury, P., \u0026amp; Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. \u003cem\u003eInternational journal for quality in health care\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(6), 349-357.\u003c/li\u003e\n\u003cli\u003eDe SK, Henke PK, Ailawadi G, Dimick JB, Colletti LM. Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship. Journal of the American College of Surgeons. 2004 Dec 1;199(6):932-42.\u003c/li\u003e\n\u003cli\u003eSchwind CJ, Boehler ML, Rogers DA, Williams RG, Dunnington G, Folse R, Markwell SJ. Variables influencing medical student learning in the operating room. The American journal of surgery. 2004 Feb 1;187(2):198-200.\u003c/li\u003e\n\u003cli\u003eBerman L, Rosenthal MS, Curry LA, Evans LV, Gusberg RJ. Attracting surgical clerks to surgical careers: role models, mentoring, and engagement in the operating room. Journal of the American College of Surgeons. 2008 Dec 1;207(6):793-800.\u003c/li\u003e\n\u003cli\u003eActon RD, Chipman JG, Lunden M, Schmitz CC. Unanticipated teaching demands rise with simulation training: strategies for managing faculty workload. Journal of surgical education. 2015 May 1;72(3):522-9.\u003c/li\u003e\n\u003cli\u003eZahn CM, Dunlow SG, Alvero R, Parker JD, Nace MC, Armstrong AY. Too little time to teach? Medical student education and the resident work-hour restriction. Military medicine. 2007 Oct 1;172(10):1053-7.\u003c/li\u003e\n\u003cli\u003eCastillo-Angeles M, Calvillo-Ortiz R, Barrows C, Chaikof EL, Kent TS. The learning environment in surgery clerkship: what are faculty perceptions?. Journal of Surgical Education. 2020 Jan 1;77(1):61-8.\u003c/li\u003e\n\u003cli\u003eAmerican College of Surgeons. ACS Residents as Teachers and Leaders. American College of Surgeons. [updated: 2024; cited: 2024 April 15]. Available from: https://www.facs.org/for-medical-professionals/education/programs/acs-residents-as-teachers-and-leaders/\u003c/li\u003e\n\u003cli\u003eAmerican College of Surgeons. ACS Surgeons as Educators. American College of Surgeons. [updated: 2024; cited: 2024 April 15]. Available from: https://www.facs.org/for-medical-professionals/education/programs/acs-surgeons-as-educators/\u003c/li\u003e\n\u003cli\u003eAssociation for Surgical Education. Educational Resources. Association for Surgical Education. [updated: 2024; cited: 2024 April 15]. Available from: https://www.surgicaleducation.com/educational-clearinghouse/\u003c/li\u003e\n\u003cli\u003eArad D, Finkelstein A. Patient safety and staff psychological safety: a mixed methods study on aspects of teamwork in the operating room. Frontiers in public health. 2022 Dec 23;10:1060473.\u003c/li\u003e\n\u003cli\u003eMcClintock AH, Fainstad TL, Jauregui J. Clinician teacher as leader: creating psychological safety in the clinical learning environment for medical students. Academic medicine. 2022 Nov 1;97(11S):S46-53.\u003c/li\u003e\n\u003cli\u003eChrouser KL, Partin MR. Intraoperative disruptive behavior: the medical student\u0026apos;s perspective. Journal of surgical education. 2019 Sep 1;76(5):1231-40.\u003c/li\u003e\n\u003cli\u003eGarner MS, Gusberg RJ, Kim AW. The positive effect of immediate feedback on medical student education during the surgical clerkship. Journal of Surgical Education. 2014 May 1;71(3):391-7.\u003c/li\u003e\n\u003cli\u003ePerera J, Lee N, Win K, Perera J, Wijesuriya L. Formative feedback to students: the mismatch between faculty perceptions and student expectations. Medical teacher. 2008 Jan 1;30(4):395-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Medical Student, Surgical Clerkship, Surgical Education, Resident Educator, Surgical Faculty","lastPublishedDoi":"10.21203/rs.3.rs-4953859/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4953859/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eWhile the operative experience is a core component of the surgical clerkship, studies have suggested interactions with strong teachers and mentors have the most significant impact on a student\u0026rsquo;s decision to pursue a surgical career. The goal of this study was to identify qualities of effective and ineffective educators from a medical student\u0026rsquo;s perspective and clarify successful educational techniques that can significantly impact medical students\u0026rsquo; surgery clerkship experiences.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative analysis of all medical student Surgery clerkship evaluations of resident physicians and surgery faculty from 2018 to 2022 at four HMS affiliated tertiary care centers. We utilized grounded theory as a means of exploring and interpreting our data. Qualitative analysis was conducted with two reviewers per the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist guidelines for qualitative research.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 1,378 faculty evaluations were analyzed with a Cohen\u0026rsquo;s Kappa of 0.85, indicating excellent inter-rater reliability. The analysis revealed six key themes that resonated with medical students during surgical clerkships: Enabling Student Involvement, Investment in Student Learners, Positive Team Environment, High Yield Teaching, Clinical Role Models, and Personal Connection. Students valued educators who allowed independence, advocated for their involvement, and engaged with them both inside and outside the operating room. Effective educators prioritized educational experiences, set clear expectations, and provided feedback. They also shaped the team environment by including students and acknowledging their contributions. Successful teaching strategies included high-yield chalk-talks, multi-modal activities, and personalized topics. Students appreciated educators who demonstrated clinical excellence and sought personal connections, valuing mentorship and efforts to know them as individuals.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSurgical residents and attendings play a significant role in shaping the educational experience of medical students on the surgical clerkship. Based on our findings, we developed the \u0026ldquo;Surgical Educator\u0026rsquo;s Compass\u0026rdquo; to provide practical guidelines for educator interventions to incorporate varied teaching strategies, involve medical students, and maximize student education during the surgical clerkship.\u003c/p\u003e","manuscriptTitle":"Medical Student Perceptions of Effective and Ineffective Educators during their Surgical Clerkship","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-23 10:33:00","doi":"10.21203/rs.3.rs-4953859/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-03-10T17:32:30+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-15T12:28:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2024-10-02T22:17:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-04T07:20:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2024-08-26T12:50:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b8488351-f8ac-4232-a6bf-091aba37355b","owner":[],"postedDate":"October 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-05-17T15:10:44+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-23 10:33:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4953859","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4953859","identity":"rs-4953859","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}