World J Surg (2011) 35:704-709
DOI 10.1007/s00268-011-0983-0
O R I G I N A L S C I E N T I F I C R E P O R T S
Defining Surgical Role Models and Their Influence
on Career Choice
P. Ravindra * J. E. F. Fitzgerald
Published online: 11 February 2011
O Societe Internationale de Chirurgie 2011
Abstract
interest in pursuing surgical careers (P = 0.0006), with 41%
Background
Positive encounters with surgeons have
of those who identified a role model interested compared
previously been shown to influence perceptions of surgical
with 17% of those who did not. Overall, 564 key qualities for
careers. Despite this, negative perceptions persist. We
a surgical role model were suggested by respondents. These
investigated whether identifying role models in surgery
were grouped by theme, with common attributes including
influences career choice and defined the ideal qualities of a
good teacher, enthusiastic, and approachable.
surgical role model as perceived by newly qualified doctors.
Conclusions
Junior doctors were twice as likely to
Methods
A 36-item questionnaire was distributed to
express interest in pursuing a surgical career if they iden-
newly qualified graduates from a large UK medical school.
tified a positive surgical role model. Changes in medical
Results were analysed using GraphPad Prism 5.00.
school demographics are occurring, with increasing pro-
Results
Questionnaires were returned by 208 of 320
portions of female and graduate-entry doctors. These
graduates (65%). Median age was 24 years (range =
groups are less likely to choose a surgical career, so pro-
23-51); 63% female, 37% male; 71% standard undergrad-
moting interest in surgery will become increasingly
uate course, 28% graduate-entry course. Overall, 131
important to maintain high-quality applicants. Defining and
respondents (63%) felt they were able to identify a surgical
promoting perceptions of surgical role models to the wider
role model; there were no statistically significant differences
surgical community may be one way of addressing this.
between gender or course type. There was a significant dif-
ference between identification of a surgical role model and
Introduction
Presented as an oral presentation at the Association of Surgeons of
The surgical specialties have traditionally been competitive
Great Britain and Ireland International Surgical Congress in Glasgow,
and popular career choices for junior doctors. In a study of
2009.
specialty choices of students about to start medical school,
P. Ravindra
general surgery has been noted to be one of the most popular
Division of Gastrointestinal Surgery, School of Graduate Entry
[1]. In recent years data from the US and Canada have shown
Medicine and Health, University of Nottingham Medical School
a decline in applications to surgical programs, most marked
at Derby, Royal Derby Hospital, Uttoxeter Road,
Derby DE22 3DT, UK
in general surgery [2]. The factors underlying this have been
extensively studied and linked to the introduction of financial
J. E. F. Fitzgerald
reimbursement for selection into primary care specialties [3],
Department of General Surgery, Chelsea and Westminster
the increasing importance of a controllable lifestyle [4], and
Hospital NHS Foundation Trust, Fulham Road,
London SW10 9NH, UK
a lack of surgical role models, amongst others [5].
This lack of role models has been a recent issue of
J. E. F. Fitzgerald (&)
interest, with several surgical associations and academics
Association of Surgeons in Training, 35-43 Lincoln's Inn Fields,
globally adopting mentorship as a key approach to address
London WC2A 3PE, UK
e-mail: edwardfitzgerald@doctors.org.uk
declining interest in a surgical career in their own countries
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World J Surg (2011) 35:704-709
705
[6, 7]. There is evidence to support this strategy. In a recent
doctors in the year group. Completed forms were collected
study of 498 colorectal surgeons, both male and female
manually in an attempt to increase the response rate, with
respondents stated that they were encouraged by same-sex
reminders sent by email. The questionnaire was not
role models [8]. Furthermore, negative experiences with a
anonymous; however, individual answers would remain
surgeon have been reported as one of the most common
confidential.
reasons for decreasing interest in a surgical career [9].
This study was undertaken by the University of Not-
Finally, in a study of important influences on the career
tingham Medical Education Unit as part of a wider inves-
choice of basic surgical trainees, it was concluded that the
tigation into medical student experience of surgical
trainer was the most common denominator [10].
teaching. The authors of this study considered the ethical
To date, no studies have examined doctors' opinions
implications in detail and did not identify any concerns. It
regarding the qualities and attributes of a surgical role
was highlighted to all potential respondents that responding
model. Our study aimed to explore these views in newly
to the questionnaire was not mandatory and completion
qualified junior doctors from a large UK medical school.
was taken as consent to participate.
We investigated whether identifying role models in surgery
influenced career choice and what external factors played a
Analysis
part in this. We then defined the key qualities of a surgical
role model as perceived by these junior doctors.
Analysis of results was undertaken using GraphPad Prism
ver. 5.00 for Microsoft Windows (GraphPad Software, San
Diego, CA, USA). P values were determined using the v2
Materials and methods
test, where P B 0.05 was considered significant. Fisher's
exact test was utilised for smaller sample sizes. Free-text
Subjects and setting
responses were categorized into groups for analysis inde-
pendently
by
both
authors
with
no
discrepancies
Newly qualified doctors from the University of Nottingham
encountered.
Medical School in the United Kingdom were invited to
participate in this questionnaire study. A total of 320
doctors graduated, with 235 participants having completed
Results
the standard undergraduate (5-year) course and 85 hav-
ing completed the accelerated graduate-entry medicine
Questionnaires were returned by 208 of 320 students who
(4-year) course. This represented a total male:female split
attended the course, giving a response rate of 65%. The
of 35%:65%.
makeup of the respondents matched that of the population
The standard undergraduate medical course entailed
sampled. The median age was 24 (range = 23-51). There
2 years of preclinical teaching followed by a 6-month period
were 130 female doctors (63%) and 78 male doctors (37%).
in biomedical research, while those on the graduate-entry
One hundred forty-eight respondents had completed the
medicine track spent 1.5 years in preclinical teaching. In
standard undergraduate course (71%), while 60 had com-
the final 2.5 years, all students carried out placements in
pleted the graduate-entry course (28%). The response rate
junior General Surgery (8 weeks), Paediatric Surgery (1 week),
of doctors from the graduate-entry medical course was
ENT (2 weeks), Ophthalmology (2 weeks), Trauma and
70% compared with 63% from the standard undergraduate
Orthopaedics (10 weeks), and senior General Surgery
course; however, this was not significantly different
(10 weeks). This translated into a minimum of 33 weeks of
(P = 0.208). These results are shown in Table 1.
exposure to practising surgeons in the setting of operating
Overall, 66 (32%) respondents stated that they were
theatres, day-case units, surgical outpatient clinics, and for-
interested in a career in surgery, while 136 (65%) said they
mal teaching sessions.
were not interested. Six people (3%) remained undecided.
Of those expressing an interest, 76% came from the
Questionnaire
A questionnaire was devised that explored the qualities and
Table 1 Demographic background of respondents
attributes of surgical role models. This consisted of free
Respondents
Male
Female
Median age
text, binomial, and 5-point Likert scale responses. In order
(% of total)
(% of total)
(range)
to receive feedback and further improve question items, the
Undergraduate course
46 (31%)
101 (69%)
24 (23-37)
questionnaire was first piloted amongst local faculty staff.
Graduate entry course
32 (53%)
28 (47%)
32 (25-51)
Comments received were discussed and the revised non-
Overall
78 (37%)
129 (63%)
24 (23-51)
mandatory questionnaire was then distributed to all junior
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706
World J Surg (2011) 35:704-709
undergraduate group, while 24% were from the graduate-
For those who had stated an interest in surgery, the link
entry course group. This difference was not statistically
between having a role model and sufficient insight into a
significant (P = 0.313). In addition, graduate-entry doctors
surgical career was investigated. Forty percent of pro-
of either gender were not more or less likely to be inter-
surgery respondents who had a role model felt that they had
ested in a surgical career than their undergraduate-course
sufficient insight into a surgical career, while only 23% of
counterparts of the same gender. There was, however, an
pro-surgery respondents who did not have a role model felt
overall equal male:female split amongst those expressing a
that they had sufficient insight into a surgical career. This
surgical interest; significantly greater numbers of female
was not statistically significant (P = 0.345).
respondents stated that they were either uninterested or
undecided about a surgical carer (P = 0.011).
Characteristics of a surgical role model
Having a surgical role model
A total of 564 key qualities for a surgical role model were
suggested by respondents. These were then standardised
Overall, 131 doctors (63%) felt that they were able to
into key words agreed to by the authors, before being
identify a surgical role model; 53 (40%) of these were male
grouped by theme. The most common attributes mentioned
and 78 (60%) female. Ninety-three (71%) had completed
include being a good teacher (14%), having enthusiasm
the standard undergraduate course, while 38 (29%) had
(10%), being student-focused (10%) and being approach-
completed the graduate-entry course. Neither gender nor
able (9%). These were then categorized by themes based
course type significantly affected the likelihood of a doctor
on features of a clinical role model as described in publi-
identifying a surgical role model.
cations from Ullian et al. [11] and Cochran et al. [12]:
A significant difference between having a surgical role
teacher, supervisor, clinician, and person. In this respect,
model and an interest in pursuing a surgical career
respondents highlighted teaching (30%), clinical (29%),
(P = 0.0006) was noted, with 53 (41%) of those identify-
and personality (25%) aspects most often, placing less
ing a role model interested in surgery. Conversely, only 12
importance on the supervisor role (15%).
(17%) respondents who did not have a role model still
Within the teacher category, respondents stated that
maintained an interest in a surgical career.
being a ``good teacher'' (45%) was key to being a good role
The link between the quality of surgical teaching and
model without elaborating on what made a good teacher.
identifying a role model was explored. Respondents were
Some respondents suggested that being student-focused,
asked to rate the quality of the surgical teaching they
knowledgeable, patient, and inspirational were important,
received in each placement as ``Good,'' ``Average,'' or
in keeping with aspects of being a good teacher. In the
``Poor.'' Five points were allocated for good teaching, three
clinician category, respondents found a caring approach
for average, and one for poor teaching. One hundred eight
toward patients most important (30%). This was followed
respondents perceived their surgical teaching as of a good
by being a competent surgeon (21%) and having good
quality, with scores between 8 and 10 points; these were
communication skills (16%). Respondents thought that an
significantly more likely to have identified a surgical role
ideal role model should most commonly have the following
model (P = 0.005). The 94 respondents who scored their
personality traits: enthusiasm (40%), confidence (10%),
teaching at six points or less were significantly less likely
and friendly manner (8%). Finally, as a supervisor, it was
to be interested in a surgical career (P = 0.006).
shown that being approachable (59%) and encouraging
(19%) were key. A summary of this data is presented in
Insight into a surgical career
Table 2.
Male and female respondents largely agreed on the ten
One hundred and eight (52%) respondents felt that they
most frequently cited key qualities. These are shown in
gained sufficient insight as a medical student to help them
Table 3. Two notable differences included having a good
choose or reject a surgical career. Of these, 24 (22%) stated
work-life balance (3% of female respondents, 0.5% of
that they were still interested in a career in surgery, while
male respondents; P = 0.067) and being encouraging
84 (78%) were uninterested or undecided. Conversely, of
(6% of male respondents, 2% of female respondents;
the 100 respondents who felt they had not received suffi-
P = 0.0499).
cient insight as a medical student, 42 (42%) still said they
were interested, while 58 (58%) chose to reject or were
undecided about a surgical career. Analysis showed that
Discussion
doctors who stated that they were interested in a surgical
career were less likely to feel that they had gained suffi-
This study has demonstrated a strong link between identi-
cient insight into a surgical career (P = 0.002).
fying a surgical role model and an interest in pursuing a
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World J Surg (2011) 35:704-709
707
Table 2 Most frequently cited characteristics grouped within each
surgical career [16]. The reasons for this have been
theme (clinical role model categorisations based on Ullian et al. [11]
explored, with one study suggesting the main disincentives
and Cochran et al [12])
to surgery were issues of lifestyle, highlighting concerns
Teacher
Clinician
Person
Supervisor
about sacrificing personal and family life for career
advancement. Interestingly half of all the women surveyed
Good teacher
Caring
Enthusiastic
Approachable
voiced these concerns, in addition to a quarter of all men
Student-
Competent
Confident
Encouraging
[17]. In order to maintain a pool of quality applicants to the
focused
profession, it becomes necessary to actively promote
Knowledgeable
Communication
Friendly
Leader
skills
medical student and junior doctor interest.
Patient
Work life balance
Fun
Mentoring
In our study, one in three respondents stated an interest
in surgery. There was, however, a significantly greater
Inspiring
Team player
Nice
Challenging
proportion of women who stated their disinterest or
Diligent
Humble
Constructive
remained undecided about a career in surgery. Coming
Job satisfaction
Respectful
Fair
from a graduate-entry course background did not seem to
Empathetic
Able
Hands off
to relate
predispose for or against a surgical career for both men and
Professional
Calm
Hands on
women.
Successful
Charismatic
Non-demeaning
Almost two in three doctors were able to identify a
surgical role model; however, there did not seem to be any
association between having a role model and gender or
course background. This is contrary to evidence in the
Table 3 Most frequently cited characteristics of a surgical role
literature which suggests that women are more likely to
model by gender of respondents
place importance on role models and mentoring [18]. Our
Male
Female
results would suggest that men also seek positive role
models for reasons that may not be dissimilar to those of
Good teacher
Good teacher
women.
Approachable
Enthusiastic
More importantly, our results would suggest that those
Competent
Student-focused
who have identified a role model are more than twice as
Student-focused
Approachable
likely to pursue a career in surgery compared to those who
Caring
Caring
have not. This was also linked to the quality of teaching
Enthusiastic
Communication skills
they received during their surgical placement. Those who
Encouraging
Competent
felt that they had received good teaching were more likely
Knowledgeable
Knowledgeable
to have had a role model, while those who perceived their
Communication skills
Work-life balance
teaching as of a poorer standard were less likely to be
interested in a surgical career. This highlights how good
surgical teachers are seen as role models, and how this can
surgical career. This is particularly relevant as recent
be used to encourage applications for surgical training
changes in the demographics of medical school intake as
programmes.
well as curricular adaptations have had wide-ranging
Specifically, in an analysis of key characteristics of a
implications for medical workforce and postgraduate
surgical role model as suggested by respondents, being a
career choices.
good teacher was identified most frequently, being inde-
There has been a widely documented decrease in cur-
pendently mentioned 77 separate times. This was followed
ricular time reserved for surgical teaching in the UK, with
by being enthusiastic, student-focused, and approachable.
some students feeling that it is inadequate [13]. The pro-
When the characteristics were grouped by theme as sug-
portion of female students entering medical school has
gested by Ullian et al. [11] as the classical features of a
increased from 40 to 60% over the last 10 years [14].
clinical role model, a clearer picture emerged in terms of
However, just 7% of surgical consultants are women and
the needs of junior doctors: being a good teacher first,
surveys of female medical students have shown that they
followed by being an effective clinician, personable, and
are less likely to choose surgery as a career [15].
finally a good supervisor. These findings are consistent
The introduction of graduate-entry medical school
with the original findings by Ullian et al. [11] where the
courses has accelerated, with 16 UK medical schools now
most emphasis was placed on the ``teacher'' aspect.
offering specific fast-track programmes. In a study of
This is particularly relevant when it has been docu-
career choices of graduate-entry students, males were less
mented that being humiliated, degraded, and shouted
likely than their undergraduate counterparts to choose a
or sworn at occurs most commonly within surgical
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World J Surg (2011) 35:704-709
specialities compared with other areas of medicine [19].
would be interesting to look at this topic from the point of
Interestingly, men have been shown to perceive the theatre
the role models, particularly to see if they have actively
environment as much less enjoyable than do women [20]. It
tried to express these valued behaviours in front of students
has also been noted that students have been disappointed
and junior doctors. Conversely, it would be useful to see
with the lack of involvement of surgeons when it came to
which behaviours in particular defined negative role mod-
medical student education [21]. Our results reflect an
els; mistreatment of allied health professionals and fellow
important need of doctors at this stage of their training
physician colleagues, unprofessionalism, and poor patient
where the most effective educators are deemed the best
dynamic have been previously cited [22].
surgeons.
Indeed, at a stage where trainees are not adept at
assessing the manual skill of a surgeon, respondents
Conclusion
defined being a good clinician mainly as one who dem-
onstrates a caring approach toward patients. It has been
This study has shown that junior doctors are twice as likely
previously shown that the surgeon-patient relationship as
to express interest in pursuing a surgical career if they have
perceived by students has adversely affected their consid-
identified a positive surgical role model. Enthusiastic and
eration of a surgical career [2].
focused surgical teachers seem to be key to this, particu-
Personality ranked third, and respondents felt that
larly those who have a good rapport with patients. Pro-
enthusiasm, confidence, and friendliness were key parts of
fessional organisations in surgery should actively promote
this. While personality itself is not something that senior
the key qualities that doctors identify, as defined by our
surgeons may be able to change, adding enthusiasm clearly
study, if surgery is to ensure that the best candidates are
sits well. The need for capable supervision came last, with
attracted to our profession.
the characteristics of approachability and encouragement
featured here. It is important to remember that the priorities
of these themes may change as trainees progress through
their careers. In particular, the need for good supervision
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Document Outline

• Defining Surgical Role Models and Their Influence on Career Choice
  • Abstract
    • Background
    • Methods
    • Results
    • Conclusions
  • Introduction
  • Materials and methods
    • Subjects and setting
    • Questionnaire
    • Analysis
  • Results
    • Having a surgical role model
    • Insight into a surgical career
    • Characteristics of a surgical role model
  • Discussion
  • Conclusion
  • References

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