Defining and Prioritizing the Needs in Surgical Education: A National Survey Study

doi:10.21203/rs.3.rs-4986437/v1

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Defining and Prioritizing the Needs in Surgical Education: A National Survey Study

https://doi.org/10.21203/rs.3.rs-4986437/v1

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Background

In a recent study of surgical education leaders, a foundational understanding of educational needs in surgery was established. However, the challenges faced by and needs of the broader surgical education community remain elusive. The aim of this study was to determine the challenges and prioritize the needs of a variety of stakeholders in surgical education.

Methods

An anonymous survey was created using previously defined categories of educational needs, including leadership, teaching, learning, research, and professional development (PD). Participants were asked to submit the challenges faced and rank their needs. The survey was distributed electronically to members of the Association for Surgical Education (ASE) and through surgery-related social media channels from March to April in 2023. The survey results were analyzed using descriptive statistics.

Results

The survey was completed by 228 respondents. The most common challenges reported were limited faculty engagement in surgical education, lack of protected time for education, limited consistent constructive feedback to trainees, limited research funding, and limited time and direction for appropriate PD. The top priorities of educational needs included improving faculty engagement, providing best-practice teaching guidelines, creating a repository of educational resources for learning, offering training to improve research skills, and getting leadership training and career development.

Conclusion

The challenges faced by a variety of stakeholders in surgical education were determined and their priorities of educational needs were defined. Surgery departments, institutional leaders, and professional organizations representing surgical educators such as the ASE can use this information to develop resources and offerings to address identified needs in surgical education and help improve its quality.

Surgical education plays a critical role in shaping the knowledge, skills, and attitudes of future surgeons; the professional development of effective surgical educators is an important component of it [1–6]. As technology and innovations advance in surgery, the practice of surgery has changed drastically over time [7–10]. These changes create gaps between the practice of surgery and surgical education. Therefore, surgical education must continue to evolve to keep up with the advancements in surgical practice. In other words, these advancements and changes continuously drive the educational needs in the training of surgeons. As both the practice of surgery and surgical education are dynamic processes, they require re-evaluations on a regular basis to ensure needs are being met.

The education needs of surgical trainees and surgical educators have received little attention in recent literature. Our preliminary work that included interviews and focus groups with surgical education leaders, surgical educators, and trainees identified five categories of needs in surgical education including leadership, teaching, learning, research, and professional development (PD) needs. We further found that stakeholders in different roles and with different responsibilities may face different challenges and have different needs. Therefore, it is necessary to obtain input from a broader group of stakeholders in surgical education to better define existing challenges and needs and determine any differences among stakeholder groups. Thus, the aim of this study was to determine the challenges faced by a variety of stakeholders in surgical education and prioritize their needs.

Following approval of the Institutional Review Board at Indiana University (#18051), we conducted a survey study to establish a deeper understanding of education needs from a broader audience in surgery [11]. We analyzed and presented the results in descriptive statistics of frequency and provided recommendations accordingly.

Data Collection and Analysis

To obtain a broader perspective on educational needs in surgery, we designed and administered an anonymous survey through Qualtrics informed by the results of the previous work that identified the categories of educational needs. Specifically, the question items were branched into five sets of questions based on the five categories of educational needs including leadership needs, teaching needs, learning needs, research needs, and PD needs. The challenges and needs identified in the previous work were integrated into the survey as the options of the multiple-choice question items under each educational needs category. The survey consisted of 15 items including 4 background information questions to identify the roles of participants, 5 checklist questions to survey the challenges participants encounter, 5 ranking questions to prioritize the educational needs, and an open-ended question to capture any extra thoughts in relation to educational needs that surgical educators and trainees would like to share (Appendix A). Some question items included the option “Other” for respondents to enter extra comments that were not listed as an option.

The survey targeted a variety of stakeholders including chair of surgery, vice chair of education, program director, associate program director, clerkship director, associate clerkship director, skills lab director, assistant skills lab director, administrator (E.g.: residency, fellowship, or clerkship coordinator), PhD educator, education researcher, teaching faculty surgeon, nurse educator, surgical fellow, surgical resident, and medical student. As the survey included branching logic, participants could skip irrelevant questions depending on the roles they held. For example, a survey respondent with a leadership position such as a program director who was involved in administrative work, teaching, research, and has professional development needs, would answer the question categories related to leadership, teaching, research, and PD needs, while a medical student would just answer questions related to their learning needs.

For the checklist questions, participants reported each challenge they experienced in each educational needs category corresponding to their roles. The tally of each reported challenge determined which challenges were more common than others in each educational needs category. The greater the tally was, the more common the challenge was, and vice versa. Depending on the number of relevant roles, some respondents may have ranked educational needs in more categories than others. For example, a surgeon in a leadership position with faculty and researcher roles would rank needs in leadership, teaching, research, and PD categories while an administrative staff member may just rank one category in PD. When ranking the needs in a category, respondents dragged an option they considered more important to the top and less important ones to the bottom. The top option was assigned with the value 1 as the first priority among all needs, and the bottom one with the greatest number equaling the number of options as the last priority. The mean score of each option was calculated to determine the overall rank of each need among all respondents. The lower the mean score was, the higher rank the need was, and vice versa. Respondents could enter extra comments under the option Other.

Survey participants were recruited through three rounds of email invitations to the ASE membership and surgery-related social media channels. The survey opened in the beginning of March and closed at the end of April 2023. The results were analyzed and are presented using descriptive statistics.

Reliability and Validity of the Study

To enhance the reliability and validity of this study, we applied two strategies: 1) Pilot-testing and 2) Subject matter expert review. The survey was pilot-tested with 9 participants including chair of surgery, program director, clerkship director, teaching faculty surgeon, education researcher, PhD educator, nurse educator, surgical fellow, surgical resident, and medical student to evaluate the content of the question items, the time needed to answer the survey, and the procedure of administering the survey. Additionally, both before and after pilot-testing the survey instrument, we also sought feedback from subject matter experts, including the ASE executive committee members, surgical educators, and trainees, to review the design and question items of the survey. Each thread of feedback was documented, reviewed, and discussed to optimize the design of the survey. The results of the pilot survey and subject matter expert review were used to finalize the survey which then received ASE executive committee approval before distribution.

The survey resulted in 228 responses from surgical education stakeholders. The survey results are reported below in three sections including the roles of respondents, the common challenges faced in surgery, and the priorities of educational needs.

Professional Roles of the Respondents

Table 1 illustrates the professional roles of the respondents in the survey. Among the 16 respondent roles, the most frequent respondents were teaching faculty surgeons (N = 61), education researchers (N = 51), and surgical residents (N = 40) while the least frequent were nurse educators (N = 3), assistant skills lab directors (N = 3), medical students (N = 7), and chairs of surgery (N = 7). There were 21 respondents who entered other roles that were not listed. Among other roles, there were 14 additional types of stakeholders. It is important to note that survey respondents could choose multiple roles that applied to their credentials.

Table 1

Professional roles of survey respondents
Professional Role	Count
Teaching Faculty Surgeon	61
Education Researcher	51
Surgical Resident	40
Clerkship Director	31
Associate Program Director	30
Skills Lab Director	23
Program Director	19
Surgical Fellow	16
PhD Educator	15
Associate clerkship Director	11
Administrator (Coordinator)	10
Vice Chair of Education	9
Medical Student	7
Chair of Surgery	7
Assistant Skills Lab Director	3
Nurse Educator	3
Other (please specify)	21
Assistant Program Director	4
DIO (Designated Institutional Official)	3
Did not specify	2
Associate Director of Integration	1
Associate Dean	1
Clinical Director	1
Clinical Researcher	1
Engineering Researcher	1
Medical Association Education Staff	1
Sr. Associate Dean, UME	1
Vice Chair, Academic Affairs	1
Admin/Educational Tool Designer	1
President of Surgical Education Association in my country	1
EdD, SERF fellow	1
Competence committee chair	1

Challenges Faced in Surgical Education

Table 2 illustrates the challenges surgical educators and trainees have experienced in surgical education based on the five categories of educational needs. This table also provides insights on the frequency of these challenges by listing the number of times each challenge was reported by survey respondents.

In the leadership needs category, respondents indicated that faculty engagement (N = 102) was the number one challenge. The primary resource related challenges included lack of funding, lack of time, and lack of human resources. Cultural and systemic challenges in surgery such as “lack of incentive for education work” and “limited health system prioritization of education” were commonly reported in the extra comments. Another notable challenge submitted was the limited resources and buy-in in community training programs resulting in a different training experience compared with academic programs.

In the teaching needs category, the number one challenge was the lack of protected time for teaching (N = 105). Generally, challenges reported here centered around two themes: One was related to training program leadership and/or administrative factors such as “difficulty providing uniform rotation experiences for residents and students” and “limited involvement of and support from department leadership.” The other theme was insufficient knowledge, skills, and attitudes of teachers such as “difficulty teaching and assessing new generations of students and residents” and “providing constructive feedback to learners.” Extra comments also related to these two themes such as “lack of faculty buy-in” and “lack of shared vision among faculty members.”

In the learning needs category, trainees considered inconsistent provision of constructive feedback (N = 38) as the biggest issue. Additionally, trainees were concerned about unclear rotation expectations, and varied rotation experiences.

In the research needs category, lack of funding (N = 90) was the top roadblock for education researchers. Similar to other categories, surgical education researchers were challenged by “lack of time, lack of funding, lack of resources, etc.” as well as systemic and cultural factors such as “lack of respect for qualitative research,” “institutional bureaucracy in processing grant funding received,” “barriers to high level of evidence,” etc. Similar to the teaching category challenges, lack of proper knowledge, skills, and/or attitude in research seemed to be a concern as respondents indicated limited expertise in conducting education research, difficulty finding statistical help with education projects, or lack of local mentorship and ongoing projects to join.

In the PD needs category, the primary issue was the lack of time or bandwidth for PD (N = 112). “Having difficulty with faculty engagement and learners’ buy-in” as well as “not knowing what and where resources are out there” were two major PD challenges. There were some cultural and systemic challenges in the PD needs category such as “lack of departmental chair recognition” and “education is not a priority.”

Table 2

Common challenges faced in surgical education
Challenges	Count
Leadership needs
Difficulty with faculty engagement in the teaching of trainees	102
Insufficient funding to support education	80
Difficulty balancing education with clinical and research responsibilities	76
Limited protected time to pursue education endeavors	72
Lack of human and other resources in training programs	63
Limited support from department/school/institution leadership	46
Difficulty finding collaborators	31
Difficulty with resident recruitment	22
Other (please specify)	9
Challenges of teaching new learners in new paradigms, the incorporation of Zoom/Teams and maintaining engagement	1
Difficulty with students’ basic knowledge	1
Faculty need development in educational topics	1
Health system priorities over education	1
Lack of incentives for education work	1
Limited time and lack of interest from residents and faculty on PD (NTS); Recruitment of minority residents	1
Networking with other surgical educators at other institutions	1
No challenges	1
Resident buy-in	1
Teaching needs
Lack of protected time for teaching	105
Difficulty balancing between trainee wellness and learning	87
Difficulty providing uniform rotation experiences for residents and students	84
Difficulty teaching and assessing new generation of students and residents	81
Lack of formal training in teaching	79
Lack of compensation for my teaching / income loss from missed clinical productivity	76
Difficulty providing constructive feedback to learners	76
Limited involvement of and support from department leadership	62
Lack of personal motivation for investing in teaching activities	31
Other (please specify):	13
N/a	2
Buy in and support from program faculty to teach and complete evaluations	1
Difficulty with other faculty who do not prioritize teaching and learning opportunities	1
Faculty/ residents are disengaged in the teaching of medical students	1
Lack of ways to stimulate students to develop skills (forces rotation)	1
Learner engagement	1
Limited Education Research Funding	1
Lack of faculty engagement; lack of method of faculty reward for teaching activities	1
Lack of shared vision with other faculty	1
Not sure this question is applicable to someone in my job position (clerical)	1
Question applies to faculty	1
Systematic factors - lack of financial support from INSTITUTION leadership (not department level)	1
Learning needs
Inconsistent provision of constructive feedback	38
Difficulty balancing work hours with personal life	32
Insufficient autonomy in the OR	31
Inconsistent rotation expectations	25
Varied rotation experiences at different sites	25
Unclear expectations for the teaching of medical students	23
Unclear expectations from residency program administration	22
Insufficient amount of training in the OR	20
Other (please specify):	2
Lack of protected time, lack of facilitators for education	1
Feedback is often after the fact and not in person or constructive	1
Research needs
Lack of adequate funding for education research	90
Difficulty balancing research with clinical responsibilities	85
Difficulty finding statistical help with education projects	67
Difficulty incorporating evidence-based methods in surgical education	59
Limited expertise to conduct education research projects	58
Difficulty keeping up with surgical education journals	53
Difficulty finding collaborators	50
Other (please specify):	6
Lack of local mentorship and ongoing projects to join; extreme institutional bureaucracy in processing grant funding received; barriers to high level of evidence	1
Lack of respect do qualitative research in my specialty	1
None	1
Not a common line of research in most departments	1
Small numbers of learners to detect differences or compare	1
Specifically, funding is not available to cover investigator salary (NIH type funding) and educators are required to "frame" Surg ed research in different contexts (e.g., Quality)... it feels like education isn't valued in its own right.	1
PD needs
Lack of time/bandwidth for professional development opportunities	112
Lack of faculty participation in faculty engagement activities	96
Not knowing what resources are available out there	71
Difficulty getting learners' buy-in	62
Not knowing what ASE resources exist	61
Lack of guidance to carry out the responsibilities required of my position	54
Other (please specify):	6
Am specifically interested in surgical PA education that seems to fall secondary to med student and fellow education	1
Difficulty connecting with collaborators	1
Difficulty getting FACULTY buy in. faculty are really disengaged, especially post COVID	1
Educational scholarship is not a priority in most departments	1
Lack of departmental chair recognition of my work as surgical educator	1
Multidisciplinary work	1

Priorities of Educational Needs in Surgical Education

Table 3 illustrates the rankings of the needs in surgical education based on the five categories of educational needs. The top priority of the needs in each category are described as follows.

In the leadership needs category, the highest priority was assigned to improving or enhancing surgery faculty engagement in education. Regarding the teaching needs, the top priority was to provide best-practice teaching guidelines to faculty surgeons. In relation to the learning needs, creating a repository of educational resources available for trainees was the highest priority. For the research needs, providing education researchers with professional development opportunities to improve or enhance their KSAs in conducting education research was the number one priority. As to the PD needs, the most pressing needs were to provide leadership development training and offer support for career development.

Open-ended responses revealed additional needs relating to connecting with others in the same specialty or program such as rural or community programs through a forum or other communication channels, focusing on diversity and leadership, establishing a training platform in low- and mid-income countries (LMICs), and offering guidelines to benchmark compensation for practicing surgeons.

Table 3

Educational needs priorities
Needs	Mean
Leadership needs (107 responses)
Provide resources to enhance faculty engagement	2.79
Provide resources for advocating for surgical education within medical school and departmental leadership	3.32
Provide guidelines for EPA implementation and other training curricula	3.58
Define expectations for different surgical educational leadership positions	4.01
Collaborate with other surgical organizations	4.55
Create tools and resources to promote diversity, equity, inclusion, and belonging at home institutions	4.75
Provide toolkits for surgical applicant selection	5.26
Other (please specify):	7.75
Centralize research resources for use at all institutions
Define expectations around funding/ surgeon FTE (not medicine FTE) for various roles in education.
Develop educational mentorship opportunities.
Develop opportunities for participation in multi-institutional education researcher
Engage with the NBME to make the clerkship exam reflect a national curriculum
Provide resources for dealing with difficult faculty
Provide resources to help faculty improve their teaching knowledge, skills, and abilities
Teaching needs (159 responses)
Provide guidelines for best-practices in teaching	3.28
Provide a repository of teaching resources (tools, curriculum, videos, etc.)	3.40
Provide resources for better training in feedback and assessment	3.56
Provide assessment tools for teaching evaluation	4.11
Provide resources for implementing teaching innovations	4.22
Provide resources that facilitate education research projects	4.36
Provide trainings and resources to enhance my teaching practices to address issues related to diversity, equity, and inclusion	5.16
Other (please specify):	7.92
Advocate for protected time and compensation for role as an educator
Best multidisciplinary approaches
Provide standards/ advocacy around protected teaching time that bodies like the RRC can use to make mandates on protected time
Learning needs (40 responses)
Provide a repository of educational resources	3.53
Provide resources for faculty training in feedback and assessment	4.00
Provide assessment tools for residents and programs	4.43
Develop curricula to better prepare medical students for residency	5.28
Provide clear rotation guidelines for medical students and residents	5.38
Provide a forum for trainees to exchange ideas and ask questions	5.58
Provide resources for managing working relationships with faculty, other residents, students, etc.	5.90
Provide trainings and resources to improve my ability to address issues related to diversity, equity, and inclusion	6.18
Promote ASE to residency programs	6.55
Provide programs for international medical graduates entering US residency	8.23
Other (please specify):	10.98
Research needs (126 responses)
Provide professional development opportunities in education research	3.55
Provide opportunities for research collaboration	3.72
Provide financial support (grants) for research	3.83
Create a community of research consultants that could help provide advice and consultation on surgical education research projects	4.00
Provide an effective way to remain up-to-date on new surgical education literature	4.90
Provide opportunities to discuss the literature with other surgical educators/ researchers	5.05
Continue supporting the new journal	5.55
Create partnerships with industry so we could have large and/or practical datasets to answer research questions	5.56
Other (please specify):	8.84
Create a process where survey participants can be recruited from the membership (like APDS)
Help with journal submissions. Feel like a bulky process
Provide small group community to help research move forward (works in progress)
This is a comment for "provide an effective way to remain up-to-date on new surgical education literature"- I think a monthly email digest of key pieces of newly published surg ed literature curated would be nice! similar to how JACS does their digest.
PD needs (136 responses)
Provide leadership development training	4.60
Provide career advice, coaching, or mentorship	4.61
Provide resources/ ideas for improved participation in faculty engagement activities at my program	4.99
Provide resources for resident teaching	5.01
Provide training on how to provide feedback to learners	5.07
Provide educational products such as pre-recorded webinars and deliverables	5.62
Provide training for navigating medical school leadership bureaucracy	6.65
Provide wellness and burnout prevention training	6.93
Provide trainings and resources to improve my ability to address issues related to diversity, equity, and inclusion	7.21
Provide training on human resource management	7.44
Differentiate offerings and resources for academic, rural, and community based programs	7.93
Other (please specify):	11.94
Too many choices to navigate

This study aimed to determine the challenges faced by various stakeholders in surgical education as well as define and prioritize their needs. Our results revealed numerous challenges and needs that are relevant to various stakeholders. One of the most frequently submitted challenges has been faculty engagement in the teaching of trainees and one of the highest priority needs identified was to provide resources that improve faculty engagement. These along with other frequently reported challenges such as lack of protected time for teaching, fear of income loss from missed clinical productivity when engaging in teaching activities, lack of funding for education and limited available resources and support from departmental leadership for teaching paint a concerning picture for surgical education. Specifically, they suggest that education is not a priority in surgical training programs but rather a secondary goal for faculty that is ok if not achieved as other (clinical) priorities supersede it. This in turn implies that the quality of teaching may be suboptimal and hence compromise the quality of the product of our training programs, i.e. our future surgeons. These results should serve as a call for action to training program leadership and institutions in general who need to step up and determine ways to promote and reward teaching efforts of their faculty to facilitate rather than impede them. Our respondents indicated that advocating with leadership for such resources is clearly a priority.

Another set of challenges related to faculty readiness for teaching. Specifically, respondents indicated that lack of formal training in teaching, or how to provide constructive feedback to learners, and difficulty teaching and assessing the new generation of trainees hampered their ability to teach. The relevant priority needs included guidelines, and resources for teaching, assessment of learners, and feedback provision to trainees. These challenges and needs again suggest that the approach of surgical training programs to teaching may be haphazard and lack appropriate structure and intentionality as they may not provide their faculty with the appropriate resources needed to teach and/ or become a good teacher. And while several institutions and surgery programs have developed curricula and resources to address this faculty need, another striking set of submitted challenges related to professional development suggested that surgical faculty lack guidance from their leadership and often do not even know what resources are available to them to improve their teaching skills. Furthermore, many responders indicated that they lack the time and bandwidth to even engage in professional development activities. These findings send a strong message to departmental and institutional leaderships asking for effective approaches that will allow for faculty time to be invested not only in teaching but also in the development of their teaching skills. In addition, they offer insights to national organizations involved in surgical education such as the ASE about existing faculty development needs around teaching.

The challenges faced by trainees responding to the survey included inconsistent provision of constructive feedback, insufficient amount of training and autonomy in the OR, and unclear or inconsistent expectations in rotations and in their programs in general. They asked for training resources for their faculty, for residency preparatory curricula, for new assessment tools, and clearer rotation expectations. These challenges and needs of trainees mirror many of the ones submitted by faculty emphasizing their importance. They also identify areas that residency program leadership can focus their attention on.

Reported challenges related to education research included lack of adequate funding, limited available expertise in education research methodologies, difficulty in finding statistical help and in identifying collaborators. Respondents asked for professional development opportunities of their education research skills, collaborative research opportunities, and financial support for education research studies. Departmental and institutional leadership can address some of these needs but there is also a role for professional organizations through the development of curricula and offerings of collaborative opportunities for their members.

Several of the needs identified in this survey can be further categorized as resource needs relating to the financial, time, human, and other resources needed to support surgical education. Such needs may be best met through efforts of local leadership by identifying and providing the resources needed for surgical education to flourish. Other needs related to the professional development of surgical faculty as educators and offer a great opportunity to professional organizations for the development of products that can help faculty develop their teaching and leadership skills in surgical education. While such products exist, for example, the Association for Surgical Education Curriculum in Education Innovation and Teaching (ASCENT) and Surgical Education and Leadership Fellowship (SELF) programs from the ASE, or the American College of Surgeons (ACS) Surgeons as Educators Course and the Certificate in Applied Surgical Education Leadership (CASEL), additional offering may be needed to fully address existing faculty needs. Finally, some of the needs related to cultural and systemic issues, such as the identified conflicts between clinical practice and teaching, may be harder to address. These may require advocacy by multiple stakeholders including surgeons, institutional leaders, surgical organizations, payers, and others to identify solutions that enable surgical faculty to more effectively engage in teaching and professional development and trainees to benefit from the anticipated improved quality of teaching.

Our study has several limitations. While we included multiple stakeholders, they were not equally represented among our responders. We therefore may have missed important insights from stakeholder groups that had few participants. Yet, the most relevant stakeholders, surgeon educators and trainees, were well represented. Another limitation is the unclear response rate of the survey because of our intention to reach as many potential participants as possible. At the time of our survey’s distribution the ASE membership had approximately 1200 members suggesting that our response rate might be around 20%, which for an online survey of a large group is above what has been previously reported [12, 13]; however, we also distributed the survey through surgical-related social media channels to reach other relevant key stakeholders, which does not allow us to calculate an accurate response rate. Additionally, the vast majority of participants were ASE members who are very engaged in surgical education, so we may not have captured the average surgeon faculty member who interacts with trainees but is not as engaged in education otherwise.

Future studies of needs assessment in surgical education should focus on community, rural-based, or military surgical programs, international surgical programs, or a specific surgical specialty, and engage additional stakeholder groups. Further, follow up studies that assess the impact of programs on addressing the identified needs, especially those dealing with the cultural and systemic challenges would be of great value to advance the field.

In conclusion, the challenges faced by a variety of stakeholders in surgical education were determined and their prioritized educational needs were defined. Surgery department and institutional leaders as well as professional organizations representing surgical educators such as the ASE can use this information to develop resources and offerings to address identified needs in surgical education and help improve its quality.

We have no known conflict of interest to disclose.

Acknowledgements

We thank the Association for Surgical Education (ASE) for providing the assistance in the recruitment of the participants for this study.

Data Availability Statements

The dataset generated and analyzed during this study are not publicly available but are available from the corresponding author on reasonable request under specific conditions.

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You are reading this latest preprint version

Defining and Prioritizing the Needs in Surgical Education: A National Survey Study

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Abstract

Introduction

Methods

Data Collection and Analysis

Reliability and Validity of the Study

Results

Professional Roles of the Respondents

Challenges Faced in Surgical Education

Priorities of Educational Needs in Surgical Education

Discussion

Conclusion

Declarations

References

Supplementary Files

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