Introduction
After completing medical school, the next hurdle for many doctors is not just applying for higher training in their chosen specialty, but deciding on a surgical or medical specialty in the first place. It is therefore essential that students are well informed of the different specialty options available whilst still at medical school, allowing them to plan their careers earlier.
A number of studies have identified that the important determinants of medical students’ and junior doctors’ choice of career include: exposure to a specialty, role models in the specialty, a variety of operative procedures, work–life balance, inspirational role models and financial income.Reference Powell, Cooles, Carrie and Paleri1–Reference Lefevre, Roupret, Kerneis and Karila6
A recent survey was conducted of trainees at five different courses or events for those interested in a career in ENT, to determine why they chose to pursue ENT as a career.Reference Bhutta, Mandavia, Syed, Qureshi, Hettige and Wong2 Forty-three core trainees and locum specialist trainees in ENT were surveyed. The results revealed that 37 per cent of the trainees chose the specialty after exposure at medical school. A further 42 per cent decided after exposure to the specialty in foundation training, and a further 18 per cent decided on ENT as a career following exposure during core training. Only 1 of the 43 participants chose the specialty after no exposure at all, and only 16 per cent of participants had not been exposed to ENT during medical school.Reference Bhutta, Mandavia, Syed, Qureshi, Hettige and Wong2
Surprisingly, ENT typically comprises less than 1 per cent of medical school curricula,Reference Davies and Elhassan7 with an average of 8.4 days of ENT surgical training.Reference Powell, Cooles, Carrie and Paleri1 Furthermore, 10 of the 26 UK medical schools do not even offer an ENT placement.Reference Khan and Saeed8 The resulting lack of understanding around what the specialty encompasses is worrying, with one-third of medical students unaware that head and neck surgery is part of ENT.Reference Powell, Cooles, Carrie and Paleri1
Ninety per cent of doctors successfully pursuing a surgical career had made that decision within one year of qualification.Reference Goldacre, Laxton, Harrison, Richards, Lambert and Parks9 However, doctors choosing to pursue a career in ENT surgery made the choice later in post-graduate training.Reference Powell and Doshi10 The curiosity and open-mindedness to search for the right career, which is present early in training, must be grasped. Hence, it is crucial to expose students to ENT in their undergraduate years.
The lack of exposure at undergraduate level may have potential implications for patient care. Of senior house officers working in the accident and emergency department, 75 per cent felt they had not received sufficient undergraduate ENT training.Reference Sharma, Machen, Clarke and Howard11 In addition, 75 per cent of general practitioners felt their undergraduate ENT training was inadequate.Reference Clamp, Gunasekaran, Pothier and Saunders12 A greater emphasis on ENT education from the beginning of training may empower students and doctors alike to go forward in their chosen careers, with confidence in their clinical judgement of ENT conditions.
The St George's Surgical Society is a student-run organisation committed to educating students in all aspects of surgery and to facilitating student engagement with surgeons. We organised a 1-day National Surgical Conference to introduce medical students from across the country to different surgical specialties and offer hands-on experience of surgical skills. This study evaluated the impact of the 1-day course on delegates’ understanding of ENT. The course aimed to change students’ perceptions of the specialty, teach an ENT-specific surgical skill and ultimately inspire a career in ENT surgery.
Materials and methods
The St George's Surgical Society hosted the St George's National Surgical Conference on 20th January 2018 at St George's Medical School at the University of London. A period of four weeks preceding the conference was assigned for advertising the event, which was open to all medical students across the country.
Of the 80 students attending the conference, 36 medical students attended both the lecture and workshop components of the conference, paying £20 each to cover the cost of equipment and animal tissue.
The ENT component of the conference took the format of morning lectures, delivered by a consultant ENT surgeon, followed by an interactive surgical skills workshop in the afternoon. The morning lecture introduced delegates to ENT surgery – outlining the training pathway and exploring the multiple subspecialties available – and interesting cases were discussed. The afternoon workshop taught the indications for tracheostomy, the surface anatomy involved and the procedure itself. The ENT consultant then demonstrated the procedure, and the students practised on their own individual ex vivo sheep larynx. Delegates rotated in groups of 8–10, with a maximum tutor-to-delegate ratio of 1:5. Tracheostomy was chosen as the designated taught skill because of its importance in practice and its relative technical simplicity to demonstrate. It was also relatively inexpensive to carry out, and could be performed on animal tissue allowing a more authentic experience.
All delegates were invited to complete a pre- and post-course questionnaire assessing: perceptions of ENT, surgical skill and utility. Regarding perceptions of ENT, delegates were shown several positive and negative perceptions of the surgical specialty pre- and post-course, and asked whether they agreed or disagreed with them. For surgical skill, delegates recorded their confidence in performing tracheostomy pre- and post-course. Regarding utility, delegates were asked to report how useful they found the course, focusing on their understanding of what a career in ENT entails and the impact the course made on their career choice.
Perceptions of ENT were recorded using a Guttman scale, which required delegates to provide a ‘Yes’ or ‘No’ answer, depending on whether or not they agreed with the perception presented to them. Confidence in performing the surgical skill and the utility of the course were recorded using a Likert scale, which required delegates to give a score of 1–5 (1 = strongly disagree; 5 = strongly agree) depending on the extent to which they found the activity useful.
Analysis of students’ perceptions of ENT pre- and post-course was performed using a McNemar test for non-parametric data. A Wilcoxon signed-rank test was performed on the results of confidence and understanding of the surgical skill. Data analysis was performed using SPSS® statistical software version 24 and Microsoft Excel® 2011, with results accepted at a 5 per cent significance level. Where applicable, the mean result was calculated, along with standard deviation from the mean to calculate the data spread.
Results
Demographic data
Thirty-six delegates completed the pre- and post-course questionnaires. One questionnaire was incomplete and consequently excluded. The resulting sample size of 35 gave a response rate of 97 per cent. Four delegates were from universities other than St George's Medical School at the University of London, accounting for 11 per cent of the delegation. All years of clinical medicine were represented (years 3, 4 and 5), whilst pre-clinical years were not completely represented, with no delegates from year two of medical school (Figure 1).
Fig. 1. Distribution of year groups among delegates.
Perceptions of ENT surgery
Table 1 outlines the changes in positive and negative perceptions of ENT surgery. There were increases in all positive perceptions and reductions in all negative perceptions of the specialty.
Table 1. Delegates’ perceptions of otolaryngology pre- and post-course
There was a 62.9 per cent (p < 0.05) increase in the positive perception that ENT provides opportunities for research, as well as a 77.1 per cent (p < 0.05) increase in the perception that ENT surgery is associated with a good work–life balance. The perception that ENT surgeons manage head and neck cancer increased by 74.3 per cent (p < 0.05). The lowest increase was a 17.1 per cent (p = 0.2) increase in the perception that ENT surgery improves patients’ quality of life, with 83 per cent of delegates believing it did so before the course and 100 per cent believing so after the course. The greatest increase was an 80 per cent (p < 0.05) increase in the perception that ENT provides opportunities for private practice.
The negative perceptions that the length of training is too long in ENT surgery, and that it offers no inter-specialty work, were both reduced, by 85.7 per cent (p < 0.05) and 80 per cent (p < 0.05) respectively. There was a 60 per cent (p < 0.05) decrease in the perception that ENT surgery involves a limited number of procedures. A 34.3 per cent (p < 0.05) decrease was observed regarding the perception that the ENT working environment is hostile, with 34 per cent of delegates believing this to be the case pre-course and 0 per cent believing it post-course.
Surgical skill findings
For all reported outcomes, there were statistically significant positive changes observed post-course, with all domains assessed scoring means within the 4.00–5.00 range post-course (Appendix 1 (online) and Figure 2). A 3.17 increase (p < 0.0001) was seen in delegates’ confidence in performing tracheostomy. The largest increase in understanding was seen in the variety of procedures carried out by ENT surgeons, with an increase of 1.86 (p < 0.0001).
Fig. 2. Delegates’ self-reported confidence surrounding tracheostomy, and their understanding of procedures and multidisciplinary team work in ENT.
Course utility findings
There was a statistically significant 77 per cent (p < 0.05) increased interest in ENT as a career choice. Delegates’ understanding of what a career in ENT entails increased by 94 per cent (p < 0.05) (Appendix 2 (online) and Figure 3).
Fig. 3. Pre- and post-course percentages of delegates interested in a career in ENT and their understanding of ENT surgery.
Discussion
Demographics
Ninety-four per cent of delegates were in their clinical years of medical school. Whilst it would have been interesting to have a greater cohort of pre-clinical students, the sample provides insight into the understanding and confidence of clinical students. The representation of clinical years is encouraging considering this group of students are more likely to be giving thought to their career, and indeed specialty choice, which they must chose sooner than their pre-clinical counterparts.
Change in perception of ENT surgery
The benefit of the consultant-led morning lecture was clear, with students’ positive perceptions of ENT increasing and their negative perceptions decreasing. Delegates gained a greater understanding of the work performed by ENT surgeons. For example, they became aware that head and neck cancer management is part of the ENT case load, with a 74 per cent (p < 0.05) increase in delegates agreeing with this positive perception. The 80 per cent reduction in the perception that ENT involves no inter-specialty work is important, as it highlights the interaction with the multidisciplinary team (MDT), often at the heart of patient care. The collaboration between surgical teams is also important, particularly when managing complex cases, and students should be aware of this work. The 60 per cent reduction in the perception that ENT surgeons only perform a limited range of procedures is very positive, with students understanding there are a multitude of skills to be mastered.
When utilising these skills and treating patients, it is important to remember that the cure should never be worse than the disease itself, with each treatment aiming to improve patients’ quality of life. Encouragingly, by the end of the course, 100 per cent of delegates believed that ENT improves patients’ quality of life, following a 17 per cent increase from 83 per cent of delegates pre-course.
In order to ensure progression through training, trainees must demonstrate their involvement in research activities, something which is set to play a greater role in obtaining a Certification of Completion of Training in the future.Reference Lee, Bhangu, Blencowe, Nepogodiev, Gokani and Harris13 Therefore, it is important that trainees are aware of the research potential in their chosen specialty. Post-course, 91 per cent of delegates were aware of the abundant research opportunities within ENT, a 63 per cent increase from 29 per cent of delegates pre-course (p < 0.05).
Work–life balance is an important factor in many trainees’ choice of specialty.Reference Powell, Cooles, Carrie and Paleri1 The 77 per cent increase in delegates believing ENT to have a good work–life balance is extremely positive. In addition, there were 86 per cent and 60 per cent decreases in the perceptions that ENT training is too long and does not provide sufficient time for a family life, respectively.
Being able to financially support a family is an important consideration when choosing any career, so a 60 per cent increase in students believing that ENT is well paid, from 37 per cent of delegates pre-course to 97 per cent post-course, is very positive. This factor, coupled with the 80 per cent increase in the perception that ENT has opportunities for private practice, may go some way to removing financial burden from the factors affecting career choice. The 66 per cent reduction in the belief that career progression in ENT is too difficult, which may discourage trainees from pursuing it as a career, makes it an attractive specialty choice.
With surgery itself still perceived as a male-dominated and often aggressive specialty, it is important that students have a good understanding of the workplace environment they are stepping into. There was a 31 per cent reduction in students perceiving ENT as a female-unfriendly specialty, with 40 per cent of delegates initially thinking this, diminishing to just 9 per cent of delegates post-course. There was also an important reduction in students perceiving ENT to be a hostile working environment, decreasing from 34 per cent of delegates pre-course to 0 per cent of delegates post-course.
The changes seen here reflect the ease with which misconceptions can be dispelled. Almost one-third of delegates pre-course believed ENT to be female-unfriendly and hostile. This is an extremely negative perception that could be detrimental to trainees joining the specialty. Our course demonstrates the ease with which these damaging misconceptions can be dispelled, with education and the opportunity to question a consultant working in the field at the heart of this process.
Surgical skill
The ability of our course to educate students in the fundamentals of a surgical skill, and teach the skill itself, proves its value in ENT education. The statistically significant improvement in delegates’ understanding of the indications for tracheostomy insertion was important, as for many patients a tracheostomy is a life-changing procedure, both mentally and physically. As with any surgical procedure, understanding the anatomy is crucial, especially in the head and neck, where there are multiple important neurovascular structures that can easily be damaged. The improved confidence in delegates’ understanding of the anatomy involved, coupled with their improved confidence in performing the tracheostomy, outlines the ability of our course to teach a new surgical skill and convey its underlying principles.
The use of animal model simulation in surgical education has been well documented.Reference Badash, Burtt, Solorzano and Carey14 Qualitative feedback on the use of ex vivo sheep larynges highlighted the value of using animal tissue compared to plastic models, with delegates relishing the life-like qualities and realistic experience. The relatively inexpensive sheep larynx provided delegates with a life-like representation of the technique that is easily reproducible for other courses.
During the tracheostomy workshop, the role of the MDT was also discussed, highlighting the role of allied healthcare professionals in tracheostomy care and education. The mean score for post-course understanding of the importance of the MDT was 4.54 out of 5.00, a significant increase from the pre-course score.
The workshop discussion also explored the variety of procedures carried out by ENT surgeons, with a significant improvement in self-reported understanding, resulting in a post-course mean score of 4.63 out of 5.00. The workshop clearly built upon the morning lectures, allowing a better understanding of the variety of procedures that ENT surgeons carry out, and the MDT involved in the planning and aftercare. With a consultant leading the workshop, the delegates had access to a wealth of knowledge and clinical experience, an invaluable resource for those coming across a specialty for the first time and for those with a previous interest.
Course utility
Figure 3 clearly outlines the dramatic changes in pre- and post-course understanding of ENT as a specialty, and delegates’ interest in a career in ENT. At the end of the course, 100 per cent of delegates felt they understood what ENT surgery entails, a staggering 94 per cent improvement from the 6 per cent of delegates pre-course. This can be attributed to the morning lectures, which explained the training pathway, outlined the inter-specialty work and MDT involved with patient care, and educated students about the procedures and techniques performed in ENT surgery. This thorough education was coupled with the afternoon workshop, which involved the teaching of an important ENT skill and allowed the students to practice.
The course provided an all-encompassing overview of ENT surgery that enabled the students to consider almost every aspect of it. This educational experience has been successful in encouraging interest in ENT surgery, one of the primary aims of the course. This is demonstrated by the incredible 77 per cent increase in delegates interested in a career in ENT, with 94 per cent of delegates interested after the course compared to the 17 per cent at the start of the day.
Qualitative feedback was also collected, which indicated the course was well received. Delegates confirmed their learning curve over the day and stated how influential the course was in inspiring a career in ENT surgery.
The future
Sparking a trainee's interest is just the beginning of their journey toward applying for ENT specialty training. Organisations like ENT-UK, and its junior organisation the Students and Foundation Doctors in Otolaryngology, play an important role in continuing the education of those interested, and in supporting their future career aspirations. The annual conferences run by both organisations are an excellent way to encourage interest and they should be promoted. Alongside this, they could provide their own 1-day courses, similar to the one organised and delivered by our group, to continue raising the interest of medical students. This can be achieved by utilising student representatives and engaging students at a local and regional level. This would increase the number of delegates attending the courses by eliminating vast travel distances.
• ENT surgery is under-represented in the saturated medical school curriculum, leaving medical students with misconceptions of the specialty
• After a 1-day ENT course, perceptions of ENT as a specialty were improved by up to 80 per cent (p < 0.01)
• There was also improved understanding of and confidence in performing tracheostomies
• Interest in an ENT career increased by 77 per cent (p < 0.01), showing that interest can be sparked early in training, rather than later as is the current trend
• A 1-day course can expose students to ENT and change their perceptions of the specialty
• The course can teach and improve confidence in an important ENT skill, whilst encouraging interest in an ENT career
There is a role for student-led societies such as the St George's Medical School Surgical Society to provide similar courses for their members. Considering that there are 32 university surgical societies represented by the Royal College of Surgeons,15 the potential for replication and expansion of this course is realistic. Medical students are well placed to liaise with clinicians and professional bodies, and organise such courses. This would benefit medical students and ENT as a specialty. It could also benefit those clinicians who engage with these endeavours, furthering their specialty and widening their teaching portfolios.
Conclusion
Under-representation of ENT in the saturated medical school curriculum, and minimal time allowed for the specialty on surgical placement, means that students do not gain exposure to the specialty. This can negatively impact future career choices and reinforce previous misconceptions of ENT. Our study has shown how a 1-day course can expose students to ENT surgery, change their perceptions of the specialty, and teach and improve confidence in an important ENT skill, all whilst inspiring an interest in ENT surgery as a career. University surgical societies are an important platform for the education of medical students and provision of learning opportunities, outside the medical school curriculum.
The St George's Medical School Surgical Society has demonstrated how a 1-day course can augment ENT surgery outside of the undergraduate curriculum. Acknowledging the small sample size present, the results still provide an insight into what can be achieved with likeminded individuals who are willing to give up their time and educate the next generation. We hope that the success of our course can be recreated on a larger scale, in multiple locations, and in different specialties. We strongly recommend other surgical societies take the initiative and help empower their members to make informed decisions about their future careers.
Competing interests
None declared
Appendix 1. Delegates’ confidence surrounding tracheostomy, and understanding of ENT procedures and MDT work, pre- and post-course
Appendix 2. Delegates interested in an ENT career and their understanding of ENT surgery, pre- and post-course
