Keywords
labor and delivery - shadowing - preclinical exposure - medical students - perceptions
- obstetrics - culture
Many medical schools are moving to increase clinical opportunities in the preclinical
years. However, even with these changes, shadowing in the preclinical years provides
contact with fields and clinical arenas that most students have never seen before.
Preclinical medical students, through shadowing, thus gain insight into various careers,
even before starting their clinical clerkships.
These experiences have the power to shape, both negatively and positively a student's
perceptions about a field and, more importantly, their future careers. In emergency
medicine (EM), at one center that surveyed shadowing students in the emergency department,
29% were less interested in a career in EM after the experience and 24% were more
interested.[1] In another similar study, also in EM, 67% of students commented that their attitudes
and interest about the field were changed by the shadowing experiences.[2] Shadowing may be especially beneficial for fields perceived by students to have
a “challenging” lifestyle, such as surgery or obstetrics and gynecology (OBGYN).
In the surgery literature, there is ample data suggest that students shadowing provide
very useful exposure and insight into the specialty and may even increase rates of
students choosing surgery as a career choice.[3]
[4]
[5]
[6] However, similar data from OBGYN is lacking. Though one recently published study
of shadowing experiences on labor and delivery (L&D) suggested that this may increase
student interest in OBGYN but was limited in that the survey was administered up to
2 years after the experience in some cases.[7] Thus, the purpose of this study was to prospectively assess the impact of shadowing
on L&D on students attitudes about OBGYN as a specialty and interest in this as a
career choice.
Methods
After obtaining exemption from the Institutional Review Board at the University of
North Carolina at Chapel Hill Office of Human Research Ethics, we conducted a three-part
prospective survey of first year medical students at the University of North Carolina
who took part in an optional shadow experience on the L&D unit between July 2016 and
June 2017.
We designed three surveys, one for students to take within a week prior to shadowing,
one to take within a week after shadowing, and one to take 3 months after shadowing.
The surveys were edited and refined by a qualitative methods expert (Teresa Edwards)
at the Howard W. Odum Institute for Research in Social Science at the University of
North Carolina. Each survey was then piloted with a small group of students for clarity
and conciseness. The first survey (presurvey) had five demographic questions, two
questions about future career plan, and three questions specifically about shadowing,
and two questions about their perceptions of OBGYN. The second survey (postsurvey)
had three questions specifically about what the student saw/did during the time on
L&D, four questions about their perceptions of OBGYN, and four questions about the
value of the experience. The final survey (far-survey) asked three questions about
career plans, three about perceptions of OBGYN, and four about the value of the experience.
At all three time points, students were asked on a scale of 1 to 5, what their likelihood
of choosing a career in OBGYN was, with 1 corresponding to “I'm certain that I will
be an OBGYN” and 5 to “I am sure that OBGYN is NOT for me.”
Each student who signed up through the OBGYN student interest group to shadow received
an e-mail with instructions from the coordinator a few days prior to their scheduled
shadow date. That e-mail was also a brief explanation of our survey and a “heads up”
about the e-mails they would be receiving. The surveys were entered into Qualtrics
(Qualtrics, Provo, UT), an electronic survey tool. Each student received an e-mail
with a link to the presurvey within a week prior to shadowing, a second e-mail with
a link to the postsurvey within a week after shadowing, and finally a third e-mail
with a link to the far-survey 3 months after shadowing. For the postsurvey and far-survey,
a reminder e-mail was sent 1 week after the original e-mail if the student had not
completed the survey.
Only students who completed at least one survey were included in the analysis. To
link each student's pre-, post-, and far-survey, a third party compiled the data using
e-mail addresses and then deidentified it, prior to any analysis. Within the survey,
students were asked to describe their time on L&D as “busy” or “slow.” Students who
shadowed on self-described “busy” days were compared with those who shadowed on self-described
“slow” days. Chi-square, t-tests, Wilcoxon's rank sum test, and Fischer's exact test were used as appropriate
to describe data within each survey. Paired t-tests were used to compare students' responses between surveys. If a student only
completed one survey, their data were not included in paired comparisons. STATA, version
13 (College Station, TX), was used to analyzed the data. Qualitative analysis was
used to identify common themes those were analyzed from free text responses.
Results
Forty-one students shadowed on L&D during the study period, of those, 31 (76%) completed
the presurvey, 21 (51%) the postsurvey, and 19 (46%) the far-survey. A total of 33
(80%) students completed at least one survey, 23 (56%) completed at least two surveys,
and 15 (37%) did all three surveys. Overall, the respondent population was 82% female,
29% had shadowed before and over half of them were considering OBGYN as a career prior
to shadowing ([Table 1]). Among the 21 students who completed the postsurvey, 13 described the day as “busy.”
Students who shadowed on slow days did not differ demographically from those who shadowed
on “busy days” with regards to gender, age, prior shadowing experience, or interest
in OBGYN as a career ([Table 1]). Vaginal deliveries, rounding, and seeing patient in triage did not differ in frequency
between these two groups ([Table 1]). However, students who shadowed on busy day were more likely to see a delivery
of some kind (100 vs. 50%, p = 0.01) and to see a cesarean section (77 vs. 13%, p < 0.01).
Table 1
Demographic information and shadowing experiences from students completing at least
one survey regarding the L&D shadow experience, and comparing respondents who shadowed
on busy versus slow days
|
Entire population of respondents
n = 33 (%)
|
Busy[c]
n = 13 (%)
|
Not busy
n = 8 (%)
|
p-Value
|
|
Female gender
|
27 (82)
|
11 (85)
|
4 (50)
|
0.15
|
|
Mean age, y, (±SD)
|
24 (±2.7)
|
24 (±2.0)
|
25 (±4.6)
|
0.60
|
|
Shadowed before
|
9 (29)
|
9 (69)
|
4 (50)
|
0.65
|
|
Completed all three surveys
|
15 (45)
|
10 (77)
|
5 (63)
|
0.63
|
|
Considering OBGYN as a career prior to shadowing
|
17 (52)
|
7 (54)
|
4 (50)
|
> 0.99
|
|
Shadowing experiences[a]
|
|
Saw any delivery
|
17 (81)
|
13 (100)
|
4 (50)
|
0.01
|
|
Saw vaginal delivery
|
9 (43)
|
6 (46)
|
3 (38)
|
> 0.99
|
|
Saw Cesarean delivery
|
11 (52)
|
10 (77)
|
1 (13)
|
0.008
|
|
Rounded with team
|
10 (48)
|
6 (46)
|
4 (50)
|
> 0.99
|
|
Saw a triage patient
|
6 (29)
|
4 (31)
|
2 (25)
|
> 0.99
|
|
Saw two activities[b]
|
9 (43)
|
7 (54)
|
2 (22)
|
0.37
|
|
Spent majority of time with attending
|
10 (47)
|
7 (54)
|
3 (38)
|
0.66
|
Abbreviations: L&D, labor and delivery; OBGYN, obstetrics and gynecology; SD, standard
deviation.
a Only includes respondents of postsurvey (n = 21).
b Activities defined as: vaginal delivery, Cesarean delivery, rounds, or triage patient.
c Only 21 students who completed the post survey were considered for busy/not-busy
comparison. There were no differences in those who did and did not complete the posttest.
[Table 2] describes students' responses to questions about the impact of shadowing on their
perceptions of OBGYN and likelihood of choosing OBGYN as a career. Students who shadowed
on a slow day did not feel that their time on L&D effected their desire to pursue
a career in OBGYN (p = 0.05). In contrast, student perceptions of OBGYN were more likely to be affected
in a positive way by people and procedures on busy days compared with slow days, (p = 0.03 and p < 0.01, respectively, [Table 2]). Among all students who shadowed, 86% would recommend the experience to a friend
who was not interested in OBGYN. Additionally, for all participants, likelihood of
becoming an OBGYN increased after shadowing (mean change = − 0.39, standard deviation
[SD] = 0.70) When compared with those who shadowed in a slow day, shadowing on a busy
day was more impactful with regards to a student's likelihood of pursuing a career
in OBGYN (mean change = −0.67, SD = 0.65 vs. 0.17, SD = 0.41, p = 0.01).
Table 2
Student responses from postsurvey regarding the impact of shadowing on their perceptions
of OBGYN
|
Entire population of respondents
n = 21 (%)
|
Busy
n = 13 (%)
|
Not busy n = 8 (%)
|
p-Value
|
|
After spending time on L&D, I am more likely pursue a career in OBGYN
|
15 (71)
|
11 (85)
|
4 (50)
|
0.15
|
|
Spending time on L&D, did not make difference in how likely I am to pursue a career
in OBGYN
|
5 (24)
|
1 (8)
|
4 (50)
|
0.05
|
|
People I worked with altered my opinion in very positive way
|
12 (57)
|
10 (77)
|
2 (25)
|
0.03
|
|
Procedures I saw altered opinion in very positive way
|
11 (52)
|
10 (77)
|
1 (13)
|
< 0.01
|
|
Considering a career in OBGYN after shadowing
|
13 (62)
|
9 (69)
|
4 (50)
|
0.65
|
|
Average change in likelihood of pursuing OBGYN[a](SD)
|
−0.39 (0.70)
|
−0.67 (0.65)
|
0.17 (0.41)
|
0.01
|
Abbreviations: L&D, labor and delivery; OBGYN, obstetrics and gynecology; SD, standard
deviation.
a Responses on a Likert's scale, 1 = I am certain that I will be an OBGYN and 5 = I
am sure that OBGYN is not for me.
In contrast, by 3 months out, this effect had declined. Among all students who completed
the far-survey, there was no change in a likelihood of pursuing a career in OBGYN
from prior to shadowing (average change = 0, SD = 0.61). When comparing students who
shadowed on busy days to those on slow days, the difference has dissipated as well
([Table 3]). However, students were still overwhelmingly described the experience as worthwhile
(95%) with 79% describing it as very worthwhile. Nearly 90% of students said they
would recommend to a friend not interested in OBGYN, including 83% of students who
shadowed on slow days. All students stated they would shadow again if they had the
chance.
Table 3
Student responses from far-survey regarding the impact of shadowing on their perceptions
of OBGYN
|
Entire population of respondents
n = 19 (%)
|
Busy
n = 10 (%)
|
Not busy
n = 6 (%)
|
p-Value
|
|
Considering a career in OBGYN
|
7 (44)
|
6 (60)
|
1 (17)
|
0.15
|
|
Shadowing very much enhanced my understanding of L&D
|
11 (69)
|
8 (80)
|
3 (50)
|
0.30
|
|
The experience was very worthwhile
|
12 (75)
|
9 (90)
|
3 (50)
|
0.12
|
|
I would recommend to a friend not interested in OBGYN
|
15 (94)
|
10 (100)
|
5 (83)
|
0.38
|
|
Average change in likelihood of pursuing OBGYN since immediately after shadowing[a]
[c] (SD)
|
0.5 (0.76)
|
0.67 (0.71)
|
0.2 (0.84)
|
0.29
|
|
Average change in likelihood of pursuing OBGYN prior to shadowing[b]
[c] (SD)
|
0.07 (0.59)
|
0 (0.47)
|
0.2 (0.84)
|
0.56
|
Abbreviations: L&D, labor and delivery; OBGYN, obstetrics and gynecology; SD, standard
deviation.
a There were nine students who responded to both post- and far-survey in the busy group,
and five in the slow group.
b There were 10 student who responded to both pre- and far-surveys in the busy group,
and five in the slow group.
c Responses on a Likert's scale, 1 = I am certain that I will be an OBGYN and 5 = I
am sure that OBGYN is not for me.
Within the qualitative analysis of the postsurvey, when asked what factors made a
difference in their likelihood to pursue a career in OBGYN, the common themes that
emerged included: exposure to the field (n = 6), “good culture” (n = 4), and positive interactions with the team (n = 4). There were four students who reported being more likely to report a career
in OBGNY after shadowing, but did not respond as to why. Themes did not differ between
students who shadowed on busy compared with slow days. Representative examples of
these themes can be seen in [Table 4]. In the far-survey, when asked about the most meaningful aspect of their experience,
10 students mentioned exposure to the field, and five mentioned interactions with
the team ([Table 4]).
Table 4
Themes and representative quotes
|
Postsurvey
|
|
|
What made you more likely to pursue a career in OBGYN after shadowing?[a]
|
Examples
|
|
Exposure to the field (n = 6)
|
“Being hands-on experience in the delivery process helped me realize that I would
love to have it be a part of my career”
|
|
Good culture (n = 5)
|
“The demeanor of the interns, the chief resident, and the attending. They seemed so
happy and really enjoyed their job”
|
|
Interactions with the team (n = 4)
|
“Getting to talk to the attendings and residents and learn about their experiences”
|
|
Far-survey
|
|
What was the most meaningful aspect of your experience?[a]
|
Examples
|
|
Exposure to the field (n = 10)
|
“I got experience that I had not had previously”
“Seeing the live birth was awesome”
|
|
Interactions with the team (n = 5)
|
“Getting to talk to the attendings and residents and learn about their experiences”
|
Abbreviation: OBGYN, obstetrics and gynecology
a Some responses were coded into more than one theme.
Discussion
In this prospective study, students shadow experiences on L&D did not impact medical
students' likelihood of going into OBGYN. However, students noted that both the people
they met and the procedures they saw while shadowing, changed their perceptions in
an overwhelmingly positive way. Additionally, the vast majority found the experience
very worthwhile and nearly all would recommend to a friend who was not interested
in OBGYN.
Throughout the preclinical and clinical years of medical school, students have exposures
and experiences almost daily that have the power to impact their perceptions of a
field and ultimately career choice. Because OBGYN is often associated with some negative
stereotypes (malpractice, long hours, etc.), any opportunity to help change that image
early in medical school is be valuable.[8] In 2005, American Congress of Obstetrics and Gynecology and Association of Professors
of Gynecology and Obstetrics emphasized the importance of early exposure through interest
groups and early career mentoring.[8] Our data suggest that interactions with people during shadowing positively impacted
perceptions of OBGYN (both quantitatively and qualitatively), hopefully helping to
dispel those negative myths.
The data regarding interest groups and impact on career choice is mixed. Data from
family medicine interest groups suggest that in positively impacts perceptions of
the field but does not actually increase family medicine as a career choice.[9]
[10] However, Blau et al found that participation in a rural medicine interest group
was impactful on career choice.[11] While this is not specialty specific, it does suggest some impact on interest group
participation. We were unable to identify any data regarding OBGYN interest group
participation and ultimate career choice.[11] However, Hammoud et al surveyed nearly 270 third year medical students after their
OBGYN clerkship, and found that the best predicator of interest postclerkship was
interest preclerkship.[12] This further underscores the importance of preclinical exposure to OBGYN.
Though shadowing on L&D is nearly ubiquitous at academic medical centers, data regarding
its value are quite limited. This study adds to the growing, albeit petite, body of
literature on this subject. Additionally, another strength of this study is the prospective
nature of the study, as well as assessing student perceptions not only before and
after, but at a third time point, 3 months after the initial experience. However,
our study is not without limitations. The biggest limitation of this study is the
low number of students. Our clerkship changed format at the same time that we began
our study, requiring students to work on Saturday mornings. Thus, the number of student
spots for shadowing was halved. In other words, each weekend, there was only one student
shadow spot instead of the two we had had the prior year. We are also limited by our
response rate. This low number also limited the statistical analysis which we could
perform. Thus, this study is really hypothesis generating and we are unable to assess
causation. No validated instrument existed for this sort of survey either. However,
by obtaining help in creating our instruments from an expert in survey design and
qualitative methods, we hoped to mitigate this somewhat. Surveys are also always at
risk for respondent bias as well.
Conclusion
A myriad of preclinical experiences exist in medical education. Data from interest
groups suggest that this sort of experience may not influence career choice but provides
a meaningful exposure.[9]
[10]
[13] This study suggests that the opportunity to shadow on L&D is a similarly meaningful
experience for students. More importantly, our data suggest that this preclinical
exposure improves perceptions of OBGYN, hopefully decreasing stereotypes of our specialty
and anxiety surrounding the clerkship. Further prospective and longitudinal studies
are needed to better assess the impact of these experiences on matched specialty,
as well as focus groups, with students to understand specifically what aspects of
this experience make it valuable. However, preclinical exposure to L&D is valuable
experience for students, which should continue to be supported by OBGYN departments
as it meaningfully impacts students' perceptions of the specialty.
