Reducing barriers, hammering out myths, fixating interest and cementing a positive image of orthopaedic surgery in medical students

16 Dec 2021

By Michael McLarnon
Fourth Year Medical Student, Queen’s University Belfast

This essay was runner-up in the 2021 BOA Medical Student Essay Prize

As a medical student, what would encourage you to consider a career in T&O and what are the perceived barriers to such a career?

Introduction

Orthopaedic operations typically have excellent outcomes1-3 with immediate impact. Emphasis on reconstruction and functional restoration over resection sets the specialty apart and requires a personalised medical approach to patients. To attract the best possible candidates it is essential to engage and empower aspiring medical students early in their careers. This essay will outline encouraging factors with suggested initiatives, followed by identifying perceived career obstacles and how to address them.

Encouraging the Next Generation

Orthopaedic student societies improve career interest4,5, bolster CVs5 and provide networking opportunities4. Electing university-based representatives is an effective method of increasing recruitment amongst medical students6. Therefore, supporting local university surgical societies by establishing a BOA medical student sub-committee, with regional representatives at each UK & Irish university, would further encourage students while promoting an orthopaedic career.

Student surgical conferences stimulate interest in surgery, particularly amongst pre-clinical students7. These conferences give students opportunities to explore a specialty in more depth, and specialty-specific workshops for orthopaedics may provide practical experience in a safe learning environment8,9

Research experience is shown to encourage students towards their field of study6. National collaborative research projects such as STARSurg10 provide an opportunity for students to have small but impactful roles in large-scale studies11. The BOA, or existing trainee research groups (CORNET, ORCA and SWORD), could similarly involve medical students in a large collaborative project.

Strong role models are an influential factor in pursuing surgery12,13 at both trainee and consultant levels14. Although often developed organically, formal mentorship ensures each mentee receives guidance15. A BOA student mentorship scheme could help connect and inspire budding orthopaedic surgeons. These meetings could be held in or outside of the workplace environment, the latter of which may facilitate discussion regarding managing work-life balance15 (often deemed a significant career barrier). 

A student’s interactions with surgeons and the number of operations observed correlate with career intentions12, as does a good teaching experience16. A recent UK study found that the average length of orthopaedic attachments has almost halved in recent decades17. Student selective components (SSCs), elective bursaries, and online educational webinars based on the BOA undergraduate syllabus could further supplement clinical placements. A six-week surgical SSC at an Irish medical school significantly strengthened surgical career aspirations and could be adapted specifically for orthopaedics18. Educational webinars facilitate interactive learning and improve accessibility to orthopaedics for interested students19; virtual reality integration, using tools such as Proximie, could facilitate practical sessions.

The opportunity to scrub is influential in encouraging medical students towards surgery20. Evidence indicates that students are more likely to attend theatres with a welcoming environment where they can actively participate14. Access to simulation is also beneficial in boosting interest20,21. High fidelity simulation such as an arthroscopic skills simulator could be made available to interested medical students22 and would help bridge the gap between textbook and operating theatre. Although less exciting, low fidelity simulations are typically cheaper and may be equally effective23

Table 1: Improving medical student interest in orthopaedics

Encouraging factors

Current initiatives

Further suggestions

Student groups and societies; locally run events

  • Local surgical/orthopaedic societies
  • BOA medical student section
  • BOTA medical student representative

 

  • BOA medical student sub-committee, with regional representatives at each UK University
  • BOA outreach to student societies
  • BOA medical student events

Student surgical and orthopaedic conferences

  • National conferences by trainee organisations with medical student tickets & sessions
  • University surgical society conferences
  • A virtual/in-person national undergraduate orthopaedic conference
  • BOA Careers day

Practical Workshops

  • BOA annual congress
  • Local student-run workshops
  • Section on website: “How to organise an orthopaedic workshop”
  • Sponsoring local society events

National Research Collaboratives

  • UK-wide surgical research collaboratives (e.g., STARSurg)

 

  • A national orthopaedic research collaborative with undergraduate opportunities

Mentorship

  • ASiT surgical mentorship scheme
  • Local university society mentorship schemes
  • BOA orthopaedic mentorship scheme for students
  • Encouraging informal mentorship

University placement

  • Elective orthopaedics +/- trauma placements
  • SSCs in orthopaedics
  • BOA elective bursary
  • Student webinars in orthopaedics
  • Examples on website of orthopaedic electives/reviews

Theatre exposure

  • Students may attend theatres/scrub during their placements/electives in orthopaedics
  • Undergraduate access to simulation tools
  • Culture of student involvement/ scrubbing in (timetabled)
  • Local workshops for students

Breaking down Barriers

Issues surrounding work-life balance are often raised, with the current generation more focussed on this than ever24. Students and junior trainees hold perceptions that a surgical career is incompatible with family life25. Consensus obtained at a recent ASiT conference concluded that better hours and more time allocated for training during working hours are the most influential factors relating to surgical recruitment and retention20. A lack of flexible training opportunities in surgery is noteworthy, and only 10% of UK surgical trainees think the information provided on less than full time (LTFT) training is adequate26.  

Despite this, it is worth reminding students that although generally reporting less leisure time, surgical trainees in the UK maintain equivocal life enjoyment to other trainees27; orthopaedic surgeons also score highly in job satisfaction28,29 and are among the happiest surgeons when balancing satisfaction with workload30

With LTFT training negatively affecting career progression31, potential barriers also exist to parenting and motherhood. Possible solutions include providing hospital childcare, implementing cultural change encouraging more equally distributed maternity/paternity leave, and individualised initiatives to maintain skills during leave (e.g., taking call or theatre attendance one day a week, simulation training and out-of-training research). Hospital childcare support and day nurseries are other potential solutions. 

A lack of female mentorship is identified in surgery, and is perhaps consequential when considering the differing decisions and barriers women in surgery face15. An American study found that females were more likely to choose orthopaedics if they had a same-sex mentor32. Additionally, evidence indicates that minority groups are underrepresented in surgical leadership across all specialties in the UK33, demonstrating a lack of role models for some students. Targeted mentorship schemes alongside appropriate equality and diversity monitoring may begin to challenge this.

A belief lingers that physical strength is a prerequisite for an orthopaedic career34,35 and a stereotype persists that orthopaedic surgeons use blunt tools and lack academic ability. Regarding intelligence, evidence suggests this is not the case36, nor is physical strength a precondition. Furthermore, as a specialty, orthopaedics has one of the best research outputs, especially in the UK37,38.

Table 2: Perceived barriers and potential solutions

Perceived barrier

Potential solutions in orthopaedics

Work-life balance

  • Providing information: realistic work schedule; trainee versus consultant; examples of consultants maintaining multiple commitments
  • LTFT training opportunities in orthopaedics
  • Challenging burnout and improving trainee support network

Parenting and motherhood

  • LTFT training adaptations and individualised programmes
  • Greater provision of hospital childcare
  • Female surgical role-models
  • Female surgical mentors/advisors

Diversity

  • Fair representation of minority groups
  • Mentorship opportunities for specific groups
  • Equality and diversity monitoring
  • Female role-models in orthopaedics

Physicality

  • Dispel the myth that this is an absolute barrier (or a barrier at all)

Conclusion

Undergraduate conferences, practical skills sessions, mentorship schemes, and research opportunities all bolster student interest. This, in synergy with removing barriers such as lack of diversity and work-life balance issues through targeted interventions, will encourage a greater number of prospective medical students from a wider demographic towards considering this rewarding career.

References

  1. Pivec R, Johnson AJ, Mears SC, Mont MA. Hip arthroplasty. The Lancet. 2012;380(9855):1768-77.
  2. Jones E, Wainwright T, Foster J, Smith J, Middleton R, Francis N. A systematic review of patient reported outcomes and patient experience in enhanced recovery after orthopaedic surgery. The Annals of The Royal College of Surgeons of England. 2014;96(2):89-94.
  3. Acquaah F, Shenouda M. A career as an orthopaedic and trauma surgeon. BMJ. 2016;352:h6172.
  4. Mickelson DT, Louie PK, Gundle KR, Farnand AW, Hanel DP. Increasing medical student exposure to musculoskeletal medicine: the initial impact of the Orthopaedic Surgery and Sports Medicine Interest Group. Adv Med Educ Pract. 2017;8:551-8.
  5. Raja U, Amin MSA, Soualhi A. 12 tips to maximise medical student exposure during surgical placements. Medical Teacher. 2020:1-5.
  6. Stumpo V, Latour K, Traylor JI, Staartjes VE, Giordano M, Caccavella VM, et al. Medical student interest and recruitment in neurosurgery: a literature review. World Neurosurg. 2020;141:448-54.e6.
  7. Al Omran Y, Chandrakumar C, Jawad A, Ahmed S, Ghanem AM. The impact of medical student surgical conferences. The Clinical Teacher. 2017;14(1):32-6.
  8. George J, Combellack T, Lopez-Marco A, Aslam U, Ahmed Y, Nanjaiah P, et al. Winning Hearts and Minds: Inspiring Medical Students into Cardiothoracic Surgery Through Highly Interactive Workshops. Journal of Surgical Education. 2017;74(2):372-6.
  9. Kamel M, Fountain DM, May P, Ashpole R. Launching an SBNS-accredited neurosurgical skills workshop for medical students and foundation trainees. Br J Neurosurg. 2017;31(6):724-6.
  10. Student Audit and Research in Surgery (STARSurg). About Us. [Available from: https://starsurg.org/about-us].
  11. Nepogodiev D, Glasbey JC. Collaborative research has direct patient benefit and merits recognition. Clinical Medicine. 2018;18(2):189.
  12. Ibrahim M, Fanshawe A, Patel V, Goswami K, Chilvers G, Ting M, et al. What factors influence British medical students' career intentions? Medical Teacher. 2014;36(12):1064-72.
  13. Musunuru S, Lewis B, Rikkers LF, Chen H. Effective Surgical Residents Strongly Influence Medical Students to Pursue Surgical Careers. Journal of the American College of Surgeons. 2007;204(1):164-7.
  14. Marshall DC, Salciccioli JD, Walton S-J, Pitkin J, Shalhoub J, Malietzis G. Medical Student Experience in Surgery Influences Their Career Choices: A Systematic Review of the Literature. Journal of Surgical Education. 2015;72(3):438-45.
  15. Entezami P, Franzblau LE, Chung KC. Mentorship in surgical training: a systematic review. Hand (N Y). 2012;7(1):30-6.
  16. Boutefnouchet T, Budair B. The perceptions and attitudes of medical students towards trauma and orthopaedic teaching: a cross-sectional study. SICOT J. 2017;3:8.
  17. Malik-Tabassum K, Lamb JN, Chambers A, West R, Pandit H, Aderinto J. Current State of Undergraduate Trauma and Orthopaedics Training in United Kingdom: A Survey-based Study of Undergraduate Teaching Experience and Subjective Clinical Competence in Final-year Medical Students. Journal of Surgical Education. 2020;77(4):817-29.
  18. Falk GA, Robb WB, Khan WH, Hill ADK. Student-selected components in surgery: providing practical experience and increasing student confidence. Irish Journal of Medical Science. 2009;178(3):267-72.
  19. Abi-Rafeh J, Azzi AJ. Emerging role of online virtual teaching resources for medical student education in plastic surgery: COVID-19 pandemic and beyond. J Plast Reconstr Aesthet Surg. 2020;73(8):1575-92.
  20. Walker NR, Deekonda P, Glasbey JC, Rashid S, Gokani VJ, Humm G, et al. Attracting medical students and doctors into surgical training in the UK and Ireland. Int J Surg. 2019;67:107-12.
  21. Zargaran D, Turki M, Farzaneh B, Subramaniam M, Motahariasl N, Zargaran A. Evaluating the effectiveness of plastic surgery simulation training for undergraduate medical students. J Plast Reconstr Aesthet Surg. 2020;73(2):276-7.
  22. Braman JP, Sweet RM, Hananel DM, Ludewig PM, Van Heest AE. Development and Validation of a Basic Arthroscopy Skills Simulator. Arthroscopy. 2015;31(1):104-12.
  23. Munshi F, Lababidi H, Alyousef S. Low- versus high-fidelity simulations in teaching and assessing clinical skills. Journal of Taibah University Medical Sciences. 2015;10(1):12-5.
  24. Ek EW, Ek ET, Mackay SD. Undergraduate experience of surgical teaching and its influence and its influence on career choice. ANZ J Surg. 2005;75(8):713-8.
  25. Harries RL, McGoldrick C, Mohan H, Fitzgerald JEF, Gokani VJ. Less Than Full-time Training in surgical specialities: Consensus recommendations for flexible training by the Association of Surgeons in Training. Int J Surg. 2015;23(suppl 1):S10-S4.
  26. Harries RL, Gokani VJ, Smitham P, Fitzgerald JEF. Less than full-time training in surgery: a cross-sectional study evaluating the accessibility and experiences of flexible training in the surgical trainee workforce. BMJ Open. 2016;6(4):e010136.
  27. Surman G, Lambert TW, Goldacre M. Doctors’ enjoyment of their work and satisfaction with time available for leisure: UK time trend questionnaire-based study. Postgrad Med J. 2016;92(1086):194-200.
  28. Davidson JM, Lambert TW, Goldacre MJ, Parkhouse J. UK senior doctors' career destinations, job satisfaction, and future intentions: questionnaire survey. BMJ. 2002;325(7366):685-6.
  29. Arora M, Diwan AD, Harris IA. Orthopaedic surgeons are highly satisfied with their careers: results from a nationwide cross-sectional study. International Journal of Orthopaedics. 2014;1(4):168-72.
  30. Messly.com. Which Specialty makes the happiest doctors? 2018. [Available from: www.messly.com/blog/which-specialty-makes-the-happiest-doctors.
  31. Daga V, Blizzard R, Dhelaria A, Hosdurga S, Hussein S, Madabhushi S, et al. Differential Attainment in Career Progression for Doctors in the UK. Sushruta Journal of Health Policy & Opinion. 2021;14(1):1-10.
  32. Hill JF, Yule A, Zurakowski D, Day CS. Residents’ Perceptions of Sex Diversity in Orthopaedic Surgery. JBJS. 2013;95(19):e144.
  33. Joseph JP, Joseph AO, Jayanthi NVG, Pereira B, Gahir J. BAME underrepresentation in surgery leadership in the UK and Ireland in 2020: an uncomfortable truth. The Bulletin of the Royal College of Surgeons of England. 2020;102(6):232-3.
  34. mayonewsreleases. Mayo Clinic Orthopedic Surgeon Inspires Young Women to Follow Her Lead. 2013. Available from: https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-orthopedic-surgeon-inspires-young-women-to-follow-her-lead/.
  35. Raja H. Overcoming the recruitment shortfall in orthopaedic surgery. 2020. [Available from: www.boa.ac.uk/resources/overcoming-the-recruitment-shortfall-in-orthopaedic-surgery.html.
  36. Subramanian P, Kantharuban S, Subramanian V, Willis-Owen SAG, Willis-Owen CA. Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study. BMJ. 2011;343:d7506.
  37. Moverley R, Rankin KS, McNamara I, Davidson DJ, Reed M, Sprowson AP. Impact factors of orthopaedic journals between 2000 and 2010: trends and comparisons with other surgical specialties. International Orthopaedics. 2013;37(4):561-7.
  38. Hohmann E, Glatt V, Tetsworth K. Worldwide orthopaedic research activity 2010-2014: Publication rates in the top 15 orthopaedic journals related to population size and gross domestic product. World J Orthop. 2017;8(6):514-23.
     
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