Effects of In-House Calls on Medical Students' Perspectives of Surgical Education and Future Career Opportunities

Abstract

Background:

It has been shown that surgical residents who took few or no in-house calls during medical school felt less prepared for the residency. In this study, our objective was to assess the impact of in-house calls carried out by medical students on their perceptions of medical training, including the influence on specialty choice.

Methods:

The students were asked to complete an anonymized questionnaire at the first and last day of their general surgery clerkship. Students were asked regarding importance for medical training and education, preparation for the internship, learning opportunities, skills acquisition; negative effects, including fatigue, negative effect over medical training, personal life, and physical and mental health derangements; and the student's perception of the residents' in-house calls and parameters affecting specialty selection: difficulty of the residency, prestige, and future career opportunities.

Results:

A total of 42 medical students responded to 84 questionnaires. There was a significant difference in the importance of calls among male students before the beginning of the clerkships compared with the end of the clerkship (4.53 versus 4.21, P = .034). At the end of general surgery clerkship, students indicated that the calls less impaired studying during the clerkship (2.5 versus 2.21, P < .05) compared with the beginning of the clerkship. Female students ranked the calls as less demanding at the end of the clerkship (2.53 versus 2.12, P < .05). The impact of the residency difficulty on the selection of their future specialty was rated higher by the students at the end of the clerkship compared with their expectations at the beginning (3.13 versus 2.85, P = .033).

Conclusions:

In conclusion, our study demonstrates that in-house calls performed by medical students during their general surgery clerkships have a significant influence on their perceptions of medical training and choice of specialty. The study also highlights the importance of gender differences in the students' perception of the importance and impact of calls on their well-being.

Introduction

Most medical schools in Israel last for 6 years. At the Hebrew University Medical School, medical students start their clinical clerkships during the 4th year. These include medicine, pediatrics, general surgery, and family medicine. The general surgery clerkship is 6-week long. During their clinical clerkships, the students are required to perform in-house calls, in which they shadow the on-call resident and perform supervised medical tasks. The surgical residents are on call for 26 hours, while the students leave the hospital at 23:00, so they do not lose the postcall day. The student calls are restricted to weekdays.

It has been shown that surgical residents who took few or no in-house calls during medical school felt less prepared for the residency, and were more likely to experience burnout symptoms.¹ In this study, our objective was to assess the impact of in-house calls carried out by medical students on their perceptions of medical training, including the influence on specialty choice, as well as their perspectives on in-house calls conducted by residents.

Methods

Institutional board approval was obtained for this study. A total of four medical student groups completed their general surgery clerkships at a university hospital between December 2021 and August 2022. Each student was assigned a random identification number, blinded to the faculty. The students were asked to complete an anonymized questionnaire at the first and last day of their clerkship. Data collected included the following: age, sex, marital status, first-degree relative physicians, and number of in-house calls performed during previous and current clerkships.

Students were asked regarding the following topics (scale of 1–5, 1 = strongly disagree/minor impact, 5 = strongly agree/strong impact):

- Parameters affecting specialty selection: difficulty of the residency, prestige, future career opportunities.

- Parameters affecting in-house calls during the general surgery clerkship: importance for medical training and education, including seeing more patients and during their initial evaluation during calls, preparation for the internship, learning opportunities, skills acquisition; negative effects, including fatigue, negative effect over medical training, personal life, and physical and mental health derangements.

- Student's perception of the residents' in-house calls: importance for surgical training and education, learning opportunities, skills acquisition, importance for the future internship year; negative effects, including fatigue, negative effect over medical training, personal life, and physical and mental health derangements.

Students were also asked to provide verbal feedback regarding the possible negative effects of in-house calls over physical and mental health. Their comments were grouped for analysis.

Statistical analyses

Descriptive statistics, such as mean, standard deviation, and median, were used to characterize the cohort. The nonparametric Mann–Whitney test and the Shapiro–Wilk test were used to compare quantitative variables between two independent groups. To assess the association between categorical variables, the Chi-square the Fisher's exact tests were used. To evaluate the trend over time, the Wilcoxon signed-ranks test for paired variables was used. All tests applied were two-tailed, and a P value of 5% or less was considered statistically significant. The statistical analyses were performed using SPSS21.

Results

A total of 42 medical students responded to 84 questionnaires. The average age of the students was 28.1 ± 2.1 years with equal gender distribution. Most (78%) of the students were unmarried, did not work as physician assistants (92.9%), and had no family members in the medical field (73.8%) (Table 1).

Table 1.

Demographics of the Cohort

Parameters	n (%)
Age (mean, years)	28.1 ± 2.1
Gender
Male students	21 (50)
Female students	21 (50)
Marital status
Single	33 (78.6)
Married	8 (19)
Divorced	1 (2.4)
Number of children
0	38 (90.5)
1	1 (2.4)
2	2 (4.8)
3	1 (2.4)
Works as a physician assistant
Yes	3 (92.9)
No	39 (7.1)
Has family members in the medical field
Yes	31 (73.8)
No	11 (26.2)

The students were asked about the contribution of performing in-house calls as a medical student during surgical clerkships to their medical training. A higher average score was given before the beginning of the clerkships (4.43 versus 4.25, P = NS). There was a significant difference in the importance of calls among male students before the beginning of the clerkships compared with the end of the clerkship (4.53 versus 4.21, P = .034). Regarding other parameters related to in-house calls, such as their contribution to preparedness for internship (3.8 versus 3.44), dedicated time for examining patients (4.07 versus 4.05), and exposure to surgical skills (3.8 versus 3.95), there were no significant differences before and after the surgical clerkships, nor were there significant differences between male and female students.

Regarding the impact of in-house calls on personal life and students' health (physical and mental), the average rating of the results was similar before and after the clerkship, and between male and female students. Regarding the statement “In-house call is demanding and impairs studying during the clerkship,” the average score was 2.5 before the clerkship and 2.21 after the clerkship (P < .05). Before the surgical clerkships, female students perceived in-house calls as more demanding and impairing quality of life compared with male students (2.53 versus 2.47 respectively, P < .05), but after the clerkship, their perception changed, and they ranked the calls as less demanding and impairing quality of life (2.12 for female versus 2.29 for male students, P < .05).

Students were asked to rank the importance of the calls to the surgical training and their impact over the surgical residents. Before the clerkship, the students ranked the calls as important for the surgical training, with an average rating of 4.38, which increased to 4.51 after the clerkship. However, they also responded that calls impair the residents' personal lives, with average scores of 4.48 before the clerkship and higher scores of 4.63 after the clerkship (P = NS).

The impact of the residency difficulty on the selection of their future specialty was rated higher by the students at the end of the clerkship compared with their expectations at the beginning (3.13 versus 2.85, P = .033). The statistical difference was more significant among female students, with an average score of 2.71 before the clerkship and 3.05 after the clerkship (P = .02). Among male students, the scores were higher compared with female students both before and after the clerkship (3 and 3.21 respectively, P = NS).

At each time point (before and after the clerkship), male students rated the influence of the prestige of the specialty choice as higher compared with female students, regardless of the difficulty of the residency (3 versus 2, P = .021). Among female students, the rating of prestige decreased significantly after the clerkship (from 2.05 to 1.9, P = .032), whereas for male students, the rating increased (from 2.9 to 3.35, P = NS).

Students were asked regarding future career path before and after the clerkship. Only 16 (38%) students responded at the beginning of the clerkship. Of these, two students indicated general surgery as a potential future career path, and five indicated a surgical specialty (nonspecific). After the clerkship, 20 students responded (47%, P = NS). A higher rate of students indicated both general surgery (N = 5) and a nonspecific surgical specialty (N = 6) as a potential future career path (P = NS).

Verbal comments

The students' verbal comments were grouped into 8 categories and are listed in Tables 2 and 3. Fifteen students responded to the impact of the calls over the students' health.

Table 2.

Verbal Comments: Impact over the Student's Health

	Before the clerkship (N = 15)	After the clerkship (N = 16)	P
Nutritional	7	0	.02
Obesity	3	0	.15
Sleep deprivation	8	12	.015
Increased risk for motor vehicle accidents	4	5	.27
Increased cancer risk	1	0	.41
Mental health impairment/depression	6	2	.38
Pregnancy loss risk	0	0	.8
Hypertension/coronary artery disease/diabetes/dyslipidemia risk	0	0	.8

P < 0.05 was considered statistically significant. Difference of bold items was significant.

Table 3.

Verbal Comments: Impact over the Resident's Health

	Before the clerkship (N = 30)	After the clerkship (N = 28)	P
Nutritional	16	14	.95
Obesity	8	4	.36
Sleep deprivation	20	23	.25
Increased risk for motor vehicle accidents	9	10	.54
Increased cancer risk	1	1	.9
Mental health impairment/depression	20	17	.99
Pregnancy loss risk	4	2	.52
Hypertension/coronary artery disease/diabetes/dyslipidemia risk	5	0	.03

P < 0.05 was considered statistically significant. Difference of bold items was significant.

More students commented that calls have a negative impact over the students' nutrition before compared with after the clerkship (46% versus 0%, P = .02). A higher rate commented of sleep deprivation at the end of the clerkship (50% versus 75%, P = .015). Thirty students responded to the impact of the calls over the resident's health. A lower rate of students commented on call impact over metabolic syndrome development at the end of the clerkship (16.6% versus 0%, P = .03).

Students' health concerns included the following statements:

Irregular meals that may cause obesity.

Mental stress and depression.

Fatigue that may lead to motor vehicle accidents.

Failure to take medications at regular hours.

Only two students commented that calls have no impact over physical and mental health.

Verbal comments of the students' view of the call impact over the residents' quality of life included the following:

Stress and depression.

Irregular meals that may cause obesity and metabolic syndrome.

Fatigue that may lead to motor vehicle accidents.

Fatigue impairs judgment and decision-making.

Stress promotes smoking.

Discussion

The present study aimed to evaluate the influence of in-house calls performed by medical students during the general surgery clerkship on their perceptions of medical training and the impact of in-house calls made by residents. The findings shed light on the experiences and attitudes of medical students regarding in-house calls, providing valuable insights for improving the educational environment and addressing potential negative effects. It has been previously shown that surgical residents who took few or no in-house calls during medical school felt less prepared for the residency and were more likely to experience burnout symptoms.¹

The results of this study revealed several important findings. First, the difficulty of residency was found to have a significant influence on the selection of future specialties among medical students—the impact of residency difficulty on specialty selection was rated higher by students at the end of the clerkship compared with their expectations at the beginning. This finding suggests that exposure to the challenging nature of surgical training during in-house calls influenced students' perceptions and considerations of different specialties. This finding is similar to previous studies highlighting the role of lifestyle and work–life balance as a major factor influencing medical students' choice of specialization.² Levaillant et al. published a meta-analysis that showed that prestige and income were more important in non-Western studies, whereas place of practice and role modeling or academic status was pointed out principally in Western studies.³

Mazeh et al. reported a survey in which medical students were asked regarding factors deterring medical students from choosing general surgery residency. Professional interest and satisfaction were ranked as the most important factors for choosing general surgery residency. The strongest deterrents from general surgery were doctors' inter-relationships and compromised lifestyle.⁴

Gender differences were also observed in relation to the influence of residency difficulty and the perception of prestige. Female students exhibited a more significant change in their ratings regarding residency difficulty after the clerkship, indicating a potential shift in their perception of the challenges associated with surgical training. Furthermore, male students consistently rated the influence of prestige higher compared with female students, regardless of residency difficulty. These gender differences may reflect variations in career aspirations and priorities among medical students.

Previous studies have shown that gender influences the choice of several specialties: in the United States, in 2000 and 2011, female general surgery residents comprised 21% and 36% of all general surgery residents. This gap is closing, as in the last decade, women have comprised 50% of U.S. medical school graduates, and the female/male ratio has been rising from 1:2.4 to 1:1.7.⁵ Further larger scale studies are required to assess these trends in Israel.

This study assessed the importance of in-house calls performed by medical students during general surgery clerkships. Overall, students rated the contribution of in-house calls to their medical training highly, indicating their recognition of the learning opportunities and skill acquisition provided through these experiences. Male students rated the importance of in-house calls higher before the clerkships compared with female students, suggesting the potential differences in perceived educational value. A further explanation may be the greater importance of work–life balance reported by female students, which may affect their scores.

Regarding the impact of in-house calls on personal life and health, no significant differences were found between male and female students. However, there was a notable decrease in female students' perception of in-house calls as demanding and impairing their quality of life after the clerkship. This change in perception may reflect the students' adaptation to the demands of in-house calls over time or a greater understanding of the necessary sacrifices and challenges associated with surgical training.

The verbal comments provided by students further highlighted important aspects related to the impact of in-house calls. Some students expressed concerns about the negative effects of calls on their nutrition and sleep, while others mentioned the potential impact of calls on the development of metabolic syndrome among residents. These comments emphasize the need for further attention to the well-being and work–life balance of both students and residents during in-house call rotations. Gilbey et al. published a cross-sectional study of 2160 medical students in Israel, which revealed a 50% burnout rate. The study showed that female gender, age younger than 25, advanced year of study, and not being a parent are all significantly correlated with higher levels of burnout.⁶

Only two students commented that the calls have no negative impact over the students or residents' health, but no student commented that calls contribute to medical training. This raises the concern of an unrealistic perception of the calls, and some of the students made these comment before performing a single call during medical school. These findings may come in line with a campaign of shortening call durations in Israel led by residents' organization.⁷ This may also be related to stricter work–life balance expectations of young millennial and generation Z (Gen Z).⁸

The negative effects of 24-hour calls have been investigated by several studies with conflicting results.^9,10 Shortening shifts have been reported to have both positive and negative effects over patient care and residents' training, lifestyle, and well-being. Landrigan et al.¹¹ reported a higher rate of serious errors among intensive care unit residents who were assigned shorter shifts (97.1 versus 79.0 per 1000 patient-days; relative risk, 1.53). This could potentially be attributed to an increased number of handovers affecting continuity of care and promoting information loss. On the contrary, Aran et al. published a study of 44 pediatric residents who were given medical decision questionnaires after 24-hour calls compared with after 3 nights of full sleep. They found that residents napping less than an hour during a night shift are prone to riskier clinical decisions.¹²

The 16-hour limit has been shown to reduce the risk of motor vehicle crash by 24%, percutaneous injury risk decreased by 40%, and the rate of attentional failures was reduced by 18% among 1st-year resident physicians.¹³ On the contrary, a meta-analysis published by Bolster et al. failed to show these negative effects.¹⁴ About half of the studies included in that meta-analysis showed no impact over the residents' well-being and a negative impact over residents' education (67%).

Limitations of the study

This study has several limitations. The sample size was relatively small, and the study was conducted at a single institution during a single academic year, which may limit the generalizability of the findings. Future studies with larger and more diverse samples are needed to confirm and expand upon these findings.

The general surgery clerkship occurs during the 1st year of clinical clerkships, which is the 4th year of medical school. The students' ability to assess their future career path at this point is limited. In addition, the students were only asked about general surgery calls, not calls during medicine and pediatrics, impacting their perception of medical training as a whole.

Another limitation of the study is that it does not address whether the students' concerns are related to the clerkship's design. Further study is needed to assess the benefits that students perceive from the additional clinical experience gained through a slightly longer workday once a week, as opposed to determining whether the added time contributed only marginally or negatively to clinical exposure.

Conclusions

This study provides insights into the perceptions of medical students regarding in-house calls and their influence on career decisions and well-being. Our findings suggest that exposure to the challenges of surgical training during in-house calls plays a significant role in shaping students' specialty choices. The study also highlights the importance of considering gender differences and addressing the potential negative effects of in-house calls on the physical and mental health of both students and residents. These findings can inform educational strategies and interventions aimed at improving the educational experience and well-being of medical students and residents.

Footnotes

Authors' Contributions

All authors confirm the following: study conception and design, data collection, analysis and interpretation of results, and article preparation.

Disclosure Statement

The authors have no disclosure of conflict of interests.

Funding Information

No funding was received for this article.

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