1. Flex-time Enhancing Surgical Education in the Third-year Medical School Curriculum

2. Penn State Hershey Medical Center Department of Surgery Adrian Ionescu BS, Eric Pauli MD, Lillian Erdahl MD, Timothy Shope MD FACS

3. Disclosures l Nothing to disclose

4. What is the problem? l Surgical clerkship lengths vary but are decreasing in length l Surgical knowledge base increasing in complexity l Students remain responsible for all aspects of surgery, including subspecialties l Surgery clerkships must provide opportunities for education across the spectrum Lind DS, Deladisma AM, Cue JI, Thomas AM, MacFadyen BV, Nesbit RR. Survey of student education in surgery. J Am Coll Surg. 2007 May;204(5):969-74

5. Educational Framework l Needs assessment l Goals/Objectives l Resource analysis l “Curriculum” design l Implementation l Evaluation

6. Structure of the Clerkship l 8 week rotation n 4 weeks core general surgery u 60% at Hershey Medical Center u 40% at affiliate sites n 2 weeks surgical specialty n 1 week Orthopedics n 1 week ENT Curet, MI. Surgical Practice of Primary Care Physicians in a rural state: Implications for curriculum design. Fam Med; 32: 97-101

7. What is Flex-Time? l One AM or PM per week l Only on 4 week Surgery rotation at HMC l Student chooses the venue n Neurosurgery clinic n Plastic surgery case n Colorectal surgery endoscopy cases n Pediatric surgery (for a future pediatrician) n Directed reading

8. What is Flex-Time? l Student MUST n Notify service prior to the day of “flexing” n Request permission to observe/participate from service/individual to which you are flexing n Submit Flex time sheet to Clerkship director to confirm use of the time n Evaluate this system l Student MAY NOT n Abuse the system n Bump another student n Overload a team n Abandon their own team

9. Methods l IRB exemption l Anonymous survey to students on completion of clerkship l Dichotomous questions n Was Flex-time used? n Was Flex-time valuable? n Did Flex-time provide broader educational opportunities? n Did Flex-time provide a more complete experience?

10. Analysis l Percentage of positive responses identified l Comparison to previous year NBME raw and percentile scores for students on same rotation (Student’s T-test) n Assess for improvement n Confirm no detriment to performance

11. Results Used Flex-Time16/3941% Valuable tool15/1693.8% More opportunity15/1693.8% More complete12/1580% 39/66 students eligible to use Flex-time completed the survey (59.1%)

12. Results

13. l How was it used? n Sub-specialty self study16 n Off service surgery7 n Journal articles1 n Breast clinic1 n CT clinic1 n Cleft palate clinic1 u Some students did more than one activity

14. Barriers l Students n “No appropriate time to talk to my team” n “I felt I was slacking” n “I worried it would affect my grade” n “Didn’t fit in for me” n “Didn’t know how my team would react” n “Difficult to make the arrangements with another service” l Residents n “Residents teased me” n “Residents gave us funny looks” n “Flex-time was greatly discouraged by my chief resident” n “Service was not very receptive”

15. Barriers l Staff n “Some doctors personally hate Flex-time” n “Should be made very explicit by a higher-up authority” n “Did not understand why I wanted to go” n “All attendings need to be aware…”

16. Overcoming barriers l Students n Empower n Encourage stewardship of their own education l Residents n “This is not your mother’s medical school” u Adapted from J. Tarpley President APDS 4/16/08 n Accept need for education of your student and your role as an educator l Staff n Buy-in n Understanding of diverse educational needs within limited time

17. Limitations l Small numbers l Student concern about “appearance” may have limited participation l Limited to only one site (University) n May be some selection bias l Early in process n Would “buy-in” be different next year?

18. Conclusions l Flex-time n Valuable educational tool n Provides more educational opportunities than traditionally offered n Creates a more complete clinical experience for MS3 surgery students n Needs further evaluation

19. Future l Further evaluation and refinement l Apply to affiliate sites l Consider application to other specialties

20. Questions