The American Journal of Surgery 191 (2006) 320 –324

Scientific paper

The value of resident teaching to improve student perceptions

of surgery clerkships and surgical career choices
Lorin D. Whittaker, Jr, M.D.a,*, Norman C. Estes, M.D.a, Jennifer Ash, M.D.a,
Lynne E. Meyer, Ph.D.b
a
Department of Surgery, University of Illinois College of Medicine at Peoria, 624 NE Glen Oak Ave., Suite 2682, Peoria, IL 61603-3135, USA
b
Department of Educational Services, University of Illinois College of Medicine at Peoria, Peoria, IL, USA

Manuscript received August 17, 2005; revised manuscript October 28, 2005

Presented at the 48th Annual Meeting of the Midwest Surgical Association, Ontario, Canada, August 14 –17, 2005

Abstract
Background: A fundamental function of attending faculty is to teach and mentor medical students, but the benefit of the resident’s role is
recognized increasingly.
Methods: Our Standardized Institutional Clinical Clerkship Assessment allows students to rate 27 factors relative to a clinical clerkship.
Scores from 1998 to 2005 were used to evaluate our surgical clerkship program and to compare resident and attending teachers. Student
surgery career choices also were monitored.
Results: Medical students routinely scored residents more highly than attending faculty. Attendings’ scores did not improve; however,
residents’ teaching and overall clerkship scores improved during the study period and paralleled students’ increased selection of a surgical
career.
Conclusions: Students perceived residents as teachers more than attendings. Residents may have significant influence over students’ career
choice by their teaching and mentoring activities, which benefit attending efforts. © 2006 Excerpta Medica Inc. All rights reserved.

Keywords: SICCA form; Teaching evaluation; Career mentoring; Learning assessment

Mentoring commonly is credited for directing others into
one’s chosen field or specialty. Although attendings recog-
nize the responsibility to mentor medical students in choos-
ing a career, students’ negative perceptions of an educa-
tional experience in a discipline may drive them away from
selecting that discipline for their career. Surgical attendings,
therefore, have a responsibility to their profession for both
education and mentoring of medical students. This is a
problematic task when attendings lack or cannot dedicate
sufficient contact hours with a student during the required
surgical clerkship to be an effective mentor and teacher of
perceived excellence.
Resident physicians have a lot of interaction with med-
ical students and the clinical time residents spend with
medical students exceeds that of attendings [1]. It has been
estimated that as much as 25% of all resident activities are
* Corresponding author. Tel.: ⫹1-309-655-6939; fax: ⫹1-309-655-3630.
E-mail address: ldwjrmd@uic.edu
spent in supervising, instructing, and evaluating students
and junior residents [1,2]. Not only the time but the quality
of education that residents contribute to medical students is
highly valued by students. Students have responded in sev-
eral reports that residents contribute more to their learning
in the clinical setting than do attendings [3,4]. The value of
residents as educators has been recognized by other inves-
tigators who are exploring means by which resident teach-
ing may be improved [5,6]. Although resident teaching is of
value to students, the motive for resident teaching may not
be altruistic in that teaching is known to be a self-learning
tool for the resident. Seely [7] evaluated this issue by study-
ing the relationship between teaching and learning in resi-
dency. Promoting residents as teachers may have additional
benefits because resident and attending teaching behaviors
are different and educationally complementary [8].
Beginning in 1998 our Department of Surgery, Univer-
sity of Illinois College of Medicine at Peoria (UICOM-P),
decided to increase efforts to enhance medical students’

0002-9610/06/$ – see front matter © 2006 Excerpta Medica Inc. All rights reserved.
doi:10.1016/j.amjsurg.2005.10.029
 L.D. Whittaker, Jr et al. / The American Journal of Surgery 191 (2006) 320 –324
education. Although student education always was valued
by our department, it held a lower priority than residency
training. Our department had not responded adequately to
repeated mediocre student perception ratings of our clerk-
ship and little effort had been made to change our teaching
program. To improve our medical students’ education and
perception of educational excellence, it was our belief and
strategy that we would make the greatest impact by placing
our emphasis on residents as teachers. We reasoned that we
could have a greater influence on changing residents’ be-
havior and improving them as teachers than to depend on
attendings’ improvement alone. This study was undertaken
to measure changes in students’ surgical education through
improvement and enhancement of residents as teachers. Our
goal was to improve students’ assessment of our surgical
clerkship, improve students’ surgical education, and pro-
mote mentoring to increase the number of medical gradu-
ates who select surgery as their career choice.
Materials and Methods
Beginning in the early 1990s, our Assistant Dean of
Medical Education and Evaluation began randomly con-
ducting a Standardized Institutional Clinical Clerkship As-
sessment (SICCA) during each academic year (Table 1).
This assessment instrument also encourages written com-
Table 1
The 27-item SICCA
1. Clarification of responsibilities at orientation.
2. Value of orientation in general.
3. Membership in the health care team (inpatient experience).
4. Membership in the health care team (outpatient experience).
5. Value of writing H&Ps.
6. Opportunity to follow-up patients through the course of illness.
7. Value of night and/or weekend call.
8. Frequency of night and/or weekend call.
9. Value of feedback about your performance from residents.
10. Frequency of feedback about your performance from residents.
11. Value of feedback about your performance from attendings.
12. Frequency of feedback about your performance from attendings.
13. Value of presenting patients to residents/attendings.
14. The percentage of patients that you were able to present.
15. Interactions with attendings in this clerkship.
16. Interactions with residents in this clerkship.
17. Interactions with nurses in this clerkship.
18. Interactions with clerical workers in this clerkship.
19. Value of lectures/conferences in meeting clerkship objectives.
20. Value of teaching rounds in meeting clerkship objectives.
21. Value of assigned readings and textbooks.
22. Congruency between readings/textbooks and objectives.
23. Opportunities to improve technical skills and do procedures.
24. Opportunities to view radiographs/images.
25. Opportunities to review microscopic or laboratory results.
26. Opportunities to review pathology pertinent to patient cases.
27. Opportunities to review findings after emergencies.
Answer choices were as follows: (1) waste of time/never did it, (2) not
helpful, (3) ok, (4) very helpful, (5) excellent.
321
ments by the student. Increased attention by our department
to this assessment by the end of the decade resulted in
routine administration of the SICCA at the end of each
required third-year clerkship. The scoring of the 27-item
SICCA form used a 5-point Likert scale to assess student
perceptions of (1) accommodations, (2) feedback, (3) inter-
action opportunities, and (4) clinical experience for each
rotation. Six of the items on the SICCA form specifically
rated the teaching of the residents and attendings.
Our surgical department routinely had ignored the
SICCA report until 1998 when we developed a strategy to
improve the perceptions of our surgical clerkship. Because
most attending faculty had been present throughout the
1990s and patterns of teaching were established, our strat-
egy for change was directed mainly at improvement in
resident teaching and mentoring. Beginning in 1998 the
following major steps for improvement were initiated:
1. Increase the part-time appointment of the Surgery
Clerkship Director to full time.
2. Recruit residents with a clear requirement of their role
as teachers.
3. Use residents in the surgery clerkship orientation.
4. Decrease call and work requirements for residents
(80 h/wk plan).
5. Require all new residents to participate in a “Resi-
dents as Teachers” course
6. Establish annual student-selected resident and attend-
ing teaching awards.
7. Provide weekly student education update at Morbidity
and Mortality conference.
8. Send letter of our departmental student clerkship as-
sessments to attendings and residents.
9. Provide each rotation’s SICCA results by letter to all
attendings and residents.
During the study period from 1998 to 2005 we tabulated
surgical clerkship students’ SICCA scores. The mean score
of all 27 SICCA items was recorded as the overall score,
and 6 attending and resident SICCA items (questions 9 –12,
15, and 16) were recorded as the attending and resident
scores. Differences in attending and resident scores were
analyzed. To determine the significance of the results we
used the independent samples t test, assuming a SD of .75.
A t test value, whether negative or positive, greater than
1.96 was significant at a P value of .05 or less.
Residency match results were used to determine stu-
dents’ career choices. Students selected into any surgical
specialty residency were recorded and results were ex-
pressed as a percentage of the graduating class. Students
selected by a general surgery residency were recorded and
results were recorded as a total of the graduating class.
Comparisons also were made of 1998 to 2004 ERAS resi-
dency match results for all University of Illinois Chicago
clinical sites: Chicago, Peoria, Rockford, and Urbana.
322 L.D. Whittaker, Jr et al. / The American Journal of Surgery 191 (2006) 320 –324

Table 2 ignored because we were using our own course-assessment

SICCA scores and career selection for surgical clerkships for academic tool. Further, we also did not believe that questions appro-
years 1998 through 2004
priate for other rotations were always appropriate for our
Year Number SICCA score t test Career surgical clerkship. Indeed, our Department Chair sent a
of
letter to the Assistant Dean of Medical Education and Eval-
students Overall Attending Resident All Surg GS
% % uation criticizing the use of the SICCA and its application to
1998 29 2.97 2.67 2.94 2.37 12 7 the effectiveness of our student program.
1999 26 3.43 2.93 3.59 5.50 11 8 The 2002 publication by Bland and Isaacs [9] was a
2000 33 3.27 2.53 3.37 7.88 15 12 helpful guide to assess why general surgery residencies
2001 22 3.15 2.06 3.23 8.96 14 12 failed to attract sufficient applicants. The philosophy of how
2002 48 3.40 2.95 3.28 2.16 22 15
to educate medical students on a surgical service has been
2003 30 3.49 2.77 3.46 6.17 29 18
2004 41 3.48 3.17 3.46 3.03 24 10 the subject of much recent debate. How to attract students to
a general surgical residency is of even more recent interest.
Scores from a 5-point Likert scale are expressed by year as the mean of
The poor results of our national surgical residency match in
27 questions (Overall) or the mean of 6 attending-/resident-specific ques-
tions expressed as “attending” or “resident.” The t test compares faculty 2001 caused Surgical Departments to rethink how surgical
with resident scores. Career choices are expressed as a percentage of the education influences medical students and their career
total graduating class to any surgical residency selection “All Surg” or only choices. The response of the Society of Surgical Chairs, the
general surgery “GS.” Association of Surgical Education, and the Association of
Program Directors in Surgery was to devote the major
portion of their annual meetings in 2002 to surgical educa-
Results tion and ways to improve student perceptions of a career
choice in general surgery.
Table 2 indicates the results of the SICCA from 1998 to Surgical education is accomplished mainly by the team
2005. Residents’ scores were higher than attendings’ scores approach; however, in the end it requires the dedication of
for every year of our study. The independent samples t test individual teachers. Although attending surgeons and lec-
comparing resident and attending SICCA scores showed turers have direct responsibility for student education, nu-
that all differences between resident and attending scores merous reports show that residents contribute more to stu-
were significant at or less than a P value of .05. Table 2 also dent learning in the clinical setting than do attendings [1–3].
shows surgical residency match results and the percent of Surgical residents provide most of the direct and bedside
graduating students who annually matched with a residency supervision to medical students in most programs. The time
in any surgical specialty and the percent who matched in residents spend in teaching activities, which includes super-
general surgery. By comparing surgical career choice with vision, instructing, and evaluating students and junior resi-
other University of Illinois Chicago sites we found the dents, has been estimated to be as high as 25% of all
selection of surgical specialties to be similar, but the Peoria resident activities and is likely to exceed the teaching time
site consistently had a higher percentage of students enter- of attending staff [4,5]. This direct supervisory responsibil-
ing a general surgical residency. The Peoria and Chicago ity and increased amount of direct contact time is an op-
sites are the only 2 sites with surgical training programs. portunity to influence medical students. Indeed, student ob-
The result of surgical residency selection at Peoria was 18% servations of the dissatisfaction and attitudes of unhappy
for all surgical specialties and 10% for a general surgery resident teachers likely has contributed to the decreased
career, whereas Chicago was 13% and 5%, respectively. selection of surgery as a career.
A recent study has assessed nicely the considerable dif-
ferences of perceptions and expectations of attendings, res-
Comments idents, and students regarding medical student education
[10]. In that study, as in ours, medical students thought that
Since the 1980s the UICOMP Department of Surgery has residents were the primary source of education in patient
had medical students evaluate residents’ teaching. This as- care. Interestingly, the attendings also credited residents as
sessment was accomplished by a 4-item evaluation form doing a better job at teaching clinical care. It was recom-
administered by the Department of Surgery and completed mended that structuring more direct attending contact and
by students at the end of each rotation. The result of this more consistent feedback might improve student percep-
evaluation resulted in little action for improvement except tions of attendings as teachers.
to shift medical students away from poorly rated resident An attendings’ increased clinical workload and greater
teachers. portion of patient care shifted to an ambulatory or non-
Similar to many departments of surgery at that time, we hospital setting decreases the opportunity for repeated
believed we were providing a quality educational experi- student–attending interactions regarding a patient or dis-
ence for surgical students. Prior results of our Medical ease process. The role of the resident in organizing the
Education Department’s assessment by SICCA largely were surgical team provides an opportunity for residents to
 L.D. Whittaker, Jr et al. / The American Journal of Surgery 191 (2006) 320 –324
have more student contact regarding clinical issues and
patient care. For this opportunity to be maximized, resi-
dents should see themselves as teachers and be taught
some basic education skills [11]. The UICOMP program
“Residents as Teachers” offered our residents increased
teaching skills and provided them knowledge to be quite
helpful in our student evaluations. For students who were
having difficulty with our clerkship, residents provided
valuable nurturing and teaching. When failure of a stu-
dent was discussed and considered by the surgical fac-
ulty, we found that residents had multiple and pertinent
assessments based on direct observation.
The attendings’ role in career counseling of students
was not assessed and therefore was not given appropriate
credit in this study. SICCA questions were too limited for
attendings to be judged or to receive credit for guiding
interested students toward a surgical career. However,
the opportunity to guide students may be missed if stu-
dents did not have a positive perception and experience
on a surgical clerkship, leading to a surgical career de-
cision. Our study indicated that students’ interactions
with residents clearly improved their perceptions of the
educational experience of the surgical clerkship. Al-
though never previously greater than 2.95, the mean
score for attendings finally increased to 3.17 for the last
year of the study. Although this increase may be spuri-
ous, it appears that the increased effort at student educa-
tion also has affected student perceptions and interactions
with attendings. Also contributory was the recent sched-
uling of increased interactions of faculty with students by
special faculty mentorship assignments and rotations for
rural sites without residents. Although the initial faculty
SICCA scores were low, the rating of faculty contribu-
tions to teaching has been improving. As recognition of
faculty contributions to education during the period of
this study our attendings have received several Univer-
sity teaching awards. These include 2 faculty recipients
for university-wide UIC Faculty of the Year, 3 recipients
for UICOMP Faculty of the Year, 3 recipients for
UICOMP Teacher of the Year, and 2 recipients for our
student-selected Golden Apple award. We believe that
progress is occurring in many aspects of our surgical
education program. The impetus for improvement was
our acceptance of the underlying message of the SICCA
scores. The improvement of resident scores was credited
mainly to our increased involvement of residents in stu-
dent orientation and educational responsibilities. The im-
provement of residents’ teaching performance was aug-
mented by our teaching program “Residents as
Teachers.” Residents are a very valuable educational
resource for students during their surgical clerkship. The
encouragement and rewarding of the resident as a teacher
can benefit the student, the resident, the surgical training
program, and the surgical profession.
323
References
[1] Tonesk X. The house officer as teacher: what schools expect and
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[3] Barrow MV. Medical student opinions of the house officer as a
medical educator. J Med Educ 1966;41:807–10.
[4] Byme N, Cohen R. Observational study of clinical clerkship activi-
ties. J Med Educ 1973;48:919 –27.
[5] Edwards JC, Kissling GE, Braanan JR, et al. Study of teaching
residents to teach. J Med Educ 1988;63:603–10.
[6] Bing-You RG, Greenberg LW. Training residents in clinical teaching
skills: a resident managed program. Med Teach 1990;12:305– 8.
[7] Seely AJE. The teaching contributions of residents. CMAJ 1999;161:
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[8] Tremonti LP, Biddie WB. Teaching behaviours of residents and
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[9] Bland KI, Isaacs G. Contemporary trends in student selection of
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Discussion
Dr. R. Stephen Smith (Wichita, KS): This paper offers
an important insight into the status of medical education in
the 21st century. The surgical training paradigm, which led
most of us into surgical careers, has changed dramatically
over the past 3 decades, and, in fact, many of our mentors
might not recognize or even condone the training of surgical
residents and medical students as it exists today.
The 9-point plan at UIC Peoria has obviously been quite
successful. But were there any other factors in the depart-
ment, which might explain the marked improvement in
student perceptions? For example, was there a change in
departmental leadership at either the level of chairman or
clerkship director?
Was there a significant change in the resident composi-
tion or qualifications during the study period? Did you
simply have better residents and did this improve the per-
ception of the students?
Why did faculty evaluations lag behind resident evalua-
tions? Are we, as faculty, old dogs who cannot learn new
tricks? Or do the faculty simply not accept the new training
paradigm?
Troubled clerkships at some other medical schools have
resorted to grade inflation to improve student evaluations.
Has the grade distribution and the surgical clerkship in
Peoria changed over the study period? How does it compare
to other clerkships in the medical school and around the
country for surgery?
What percentage of surgical clerkship grades is deter-
mined by resident evaluation and what impact does this
324 L.D. Whittaker, Jr et al. / The American Journal of Surgery 191 (2006) 320 –324
have on student evaluation of resident education perfor-
mance?
What impact has the mandated 80-hour workweek for
residents had on the student clerkship and student percep-
tions?
Dr. Ash: We did get a new program chairman. It was his
vision that the student perception of the clerkship would
help to model that clerkship into a positive one in the eyes
of the students and that would carry on to a positive view of
surgery as a specialty. That is a very important factor that
wasn’t given enough weight in the presentation.
I would like to think that we have better residents now,
but that is probably a little egotistical. Resident composition
has stayed the same. With the combination of this Residents
as Teachers program and the heavy weight that is placed on
us residents as educators, we now take on the responsibility
of mentoring. Awards that are presented to us throughout
the year and regular feedback on paper also encourage us.
There is an undercurrent of healthy competition among the
residents as we try to outdo one another in the teaching
arena.
Faculty evaluations, why are they lagging behind? When
posed with the task of changing the ways of an attending,
we find that the attendings are slower to change. The resi-
dents seem like they are very open and excited about the
program.
Regarding the subject of grade inflation, I don’t think
that this has been an issue in our clerkship. In fact, we
residents have been the filter when it comes to student
evaluations. Students want to be rewarded for hard work. If
you give honest grades, the students feel as though they are
getting a valid reward for the work they do.
The clerkship grades given by residents are equal in
weight to those given by the attendings.
In regards to the 80-hour workweek, I think that one of
the most daunting characteristics of the surgery residency
has been lifestyle. The 80-hour workweek has helped with
that. It has also helped to give the residents a little more time
to focus on teaching as part of their job responsibility.
Dr. James G. Tyburski (Detroit, MI): What does the
program director do with the feedback to the residents?
There were huge differences in the amount of students that
went into surgery. How do people that are interested in
surgery self-select this better rotation?
Dr. Ash: The Program Director uses the feedback to find
ways to improve teaching. The students are assigned among
the 4 campuses right after their first year. So, students don’t
come from 1 campus to another to do the surgery rotation.
Dr. Richard A. Prinz (Chicago, IL): What efforts are
you doing for your attending staff, because I think it’s a
little embarrassing to see the attending staff so low and not
having grades that are at least comparable if not better than
residents? Do you give them teaching awards or do you
provide them access to courses such as the American Col-
lege of Surgeons’ “Surgeons as Educators” course? What
things do you do or are you planning to do?
Dr. Ash: Several of our attending have won teaching
awards. It is not so much that the attendings are not teaching
or that their scores are low, it is just that they score lower
than the residents, and this demonstrates that the residents
are a bridge to the attendings. I think in order for students to
approach attendings for mentoring advice or career advice,
they first have to have an interest in surgery. The residents
act as a bridge to spur interest toward a career in surgery.