1. Introduction

Nowadays, recruitment of surgical resident physicians has been challenging in Taiwan, and it is not unusual that teaching hospitals encounter difficulties in recruiting adequate numbers of surgical physicians. This problem can be attributed to one of the factors being the extremely heavy work load, and two, the shortage of systemic didactics in perioperative training [1, 2]. Effective perioperative training should provide students with more information about knowledge and skills for operating so that more interest and intention to being surgeons might be aroused. Both these factors can affect career choice for young physicians. However, to improve the working environment by reducing working hours might lead to inadequate training in the operating room. It is necessary to develop an effective learning environment to balance learning and teaching effectiveness and working load. More effort is required to attract and recruit more young physicians through effective surgical education and training.

Perioperative training is one of the most important components of surgical education and training [3]. Traditionally, surgical education is proceeded using an apprenticeship model [4], where the learner acts as an apprentice to the qualified surgeon, observing, studying, and eventually participating in real cases. Currently, surgical education is shifting toward an emphasis on teaching and learning efficiency in an operating room, in where trainees can reap the greatest benefits from every clinical opportunity by optimizing teaching [4]. To maximize the learning effectiveness for surgical trainees in the operating room, teaching and feedback are of critical importance. However, previous studies have suggested a disparity might exist between learners and teaching faculty in terms of perioperative teaching, including preoperative preparation, intraoperative and postoperative feedback [5–8]. Therefore, how learners make judgements and receive feedback about perioperative teaching and learning should be also taken into consideration, not only the faculty staff. The learning effect is decided by the attitude and learning strategies of the students themselves [9]. The tight pace in the operating room is an undoubted challenge for perioperative training, because it must be implemented in a very short period [8, 10, 11]. Therefore, effective teaching and learning through a structured learning model is of paramount importance.

Adult Learning theory is to develop skills for self-directed lifelong learning. The theory points out that adults learn best when they know why they need to learn something, they can use self-directed learning, the learning involves real-life situations, and the stimulus for learning is internal rather than external [12]. Adult Learning Theory has been developed for over two decades, and has been applied in the field of medical education as well [13], including surgical education [14]. Development of core competencies for surgeons have relied on education in the operating theatre [15]. Adult learning principles have been perceived that could be employed regularly to improve surgical training [14].

Several measurements for learning effect of medical education have been proposed. The Accreditation Council for Graduate Medical Education (ACGME) developed a competency program in 1999 [16]. The goal of this program was to demonstrate successful achievement of well-defined clinical education outcomes. Six competencies, namely patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, medical professionalism, as well as systems-based practice, have been put forth [16].

In Taiwan, medical clerkship rotation in each surgical sub-specialist division usually takes a short period of around two weeks, and to enhance their learning performance has effectively become a very important issue. This study was conducted to evaluate the learning effect of medical students undergoing their structural perioperative training, and aimed to clarify the triangular relationships between clinical core competencies, adult learning competency, and how the interest toward being surgeons increased.

2. Materials and methods

3. Results

Altogether, 412 medical students (173 interns and 239 clerks) were enrolled in this study and 136 (33%) were female. Mean of ALQ was 30.8 (SD = 3.7). A lower quartile, median, and upper quartile of total ALQ were 28, 31, and 35 respectively, and four groups were created accordingly to represent the highest, the high, the low, and the lowest adult learning pattern adopted. Means of CCCQ were 23.7 (SD = 4.7) before and 30.0 (SD = 3.6) after perioperative training respectively. Paired Student t-test revealed there was a significant increase between pre- and post-training CCCQ (29.5, p <0.001).

Fig 1 illustrates the change of CCCQ from pre-training to post-training by four levels of adult learning pattern. The results show the increase of CCCQ across all four levels of adult learning, and they were from 21.5 (SD = 5.0) to 26.0 (SD = 2.7) for the lowest group, 23.3 (SD = 4.1) to 29.3 (SD = 2.0) for the low group, 24.4 (SD = 4.3) to 31.4 (SD = 2.0) for the high group, and 25.8 (SD = 4.3) to 33.9 (SD = 2.3) for the highest group. To examine if there was a difference of increment among four groups, we conducted a two-way repeated measure ANOVA (Table 1). The results revealed that there were differences in changes between pre- and post-CCCQ across four groups (interaction effect F = 13.0, p <0.001). That is, more increment of CCCQ was found among the highest adult learning group after complement of the structured perioperative training.

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Fig 1. Change of surgical competencies by 4 levels of adult learning pattern.

ALQ: Adult Learning Questionnaire; CCCQ: Clinical Core Competency Questionnaire; PR: percentile.

https://doi.org/10.1371/journal.pone.0262872.g001

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Table 1. Pre- and post-perioperative training surgical competencies by quartile of adult learning among medical students.

https://doi.org/10.1371/journal.pone.0262872.t001

The interest to be a surgeon in the future was 22 (5.3%) not at all, 181 (43.9%) uncertain, and 209 (50.7%) yes before perioperative training; while 14 (3.4%) not at all, 144 (35.0%) uncertain, and 254 (61.7%) yes after perioperative training. Increased interest was defined with responses of “not at all” before training becoming “uncertain” or “yes”; or those with responses of “uncertain” before training becoming “yes”. Totally, 61 (14.8%) students expressed increased interest to be a surgeon in the future (53 from undetermined to be positive, 7 from negative to be undetermined, and 1 from negative to be positive).

4. Discussion

The main findings of this study are as follow: (1) improvement of clinical core competency after completing the structural perioperative training; 2) improvement of clinical core competency was positively correlated with adult learning patterns; and 3) more learners expressed interest to be a surgeon in the future after perioperative training.

Roberts et al applied the briefing, intraoperative, and debriefing model for teaching in the operation room in 2009 [10], the modified structured perioperative teaching of this study, emphasizing the written record for debriefing, offers an effective learning and teaching model for perioperative training. The structured perioperative teaching model matched the learning styles with teaching styles by guided discovery learning [15]. Students’ perceptions of perioperative teaching by faculty surgeons were strongly associated with the model. Postoperative feedback played an important role to encourage and motivate the learners to furthered self-directed learning [21, 22]. Application of the clinical reasoning during debriefing feedback also effectively stimulate the learners to know what they have not known yet and what they need to know, and resulted in strong reflection and awareness of the importance of the adult learning. This inward awareness process made the students to actively learn better clinical competency related to the real patient, and adjusted and improved the self-weakness [11, 23]. The duty hours of surgical residents have been restricted by law since 2019 in Taiwan [24], in order to improve trainees’ well-being and patient safety [25]. In the structural perioperative teaching, the learners were briefed with the preoperative preparation, operative indications, and objectives of surgery by the attending surgeon beginning from scrubbing time to start of operation. During the intraoperative teaching, surgical anatomy, instrument handling, surgical technique, details of procedure, independent practice, clinical reasoning, teamwork, and ethical issues would be intensively discussed between trainers and trainees. The possible complications, postoperative care, and prognosis would be included in the debriefing after surgery. Our findings suggested that the medical students perceived self-improvement in surgical competency with this structural perioperative training model.

There was a substantial number of medical students expressing increased interest to be a surgeon by nearly 15% after the perioperative training. Regardless of pre- or post-training, the interest rates of being a surgeon in this study were higher than those expected and compared to results of previous a study [26]. A possible explanation of this finding was that positive response to the research question did not necessarily exclude other career choices among the young medical students. Most medical students keep their career choice at a broad range during the beginning of the clinical learning stage; however, in terms of enrollment of more young surgeons, the findings of this study remain positive, as personal interest is usually the main factor influencing the final decision of career choice among junior doctors [27]. More importantly, this perioperative training not only provided an effective training program for medical students but possibly an efficient method to recruit more young doctors into the surgical field as well.

The more adult learning patterns medical students adapted, the higher the improvement of surgical competency after the structural perioperative training gained. Medical education has been designed to equip learners with the knowledge, clinical skills, and professionalism required to be a competent physician who delivers patient care with quality. As the perioperative training in this study required learners to experience more self-directed experiential learning, feedback and more teacher-learner-interaction, it could be expected that medical students with more adult learning patterns would have more effective learning outcomes represented by competency. The study emphasizes that definitely clear learning effects refers to so-called aesthetic education with the theoretic background of phenomenology of perception, meaning that learners pick up information via a variety of channels such as visual observation, aural listening, oral communication, cutaneous sensation, with olfactory and tactile sensation, and at the same time they combine all these perceptions, construct new meanings of learning objectives given during self-directed learning, thoughtful acquisition of protocols, and hands-on practice as well [28]. In brief, the learning outcome revealed an optimistic result, which was similar to our previous study [21].

Our study has some limitations. Firstly, it was a quasi-experiment design without a control group, and although there were two measurable outcomes, being clinical core competency and interest to be a surgeon merited the perioperative training, it was still difficult to definitively confirm the effectiveness of an intervention without a controlled group. Secondly, as study participants were enrolled from a single teaching hospital, the findings should be cautiously extrapolated to other populations. Thirdly, assessment in this study mainly relied on self-rating, possibly leading to some degree of rater bias. An objective assessment, particularly for competency, would improve the study results. Finally, future studies with large study samples are necessary to confirm the findings.

5. Conclusions

A structural perioperative teaching model was re-developed, which included a written record for more focused feedback. The training improved clinical core competency and increased the interest of the students to be a future surgeon. The more adult learning patterns medical students develop, the more they will benefit from the training. Those whose interest in being surgeons increased improved their surgical competency more than their counterparts in this study.

Supporting information

Acknowledgments

The authors would like to acknowledge the contributions of all the participating students, colleagues, and research assistant Ching-Yu Hu who assisted with manuscript preparation.