Keywords
labor and delivery - preclinical exposure - shadow - obstetrics
Shadowing, or observing medical providers and procedures, is an experience that is
common in medical education. Shadowing medical providers has been demonstrated to
increase exposure to a field of practice and enhance learning for a wide spectrum
of learners.[1]
[2]
[3]
For medical students in the preclinical years, shadowing offers exposure to the inpatient
services and patient care prior to initiation of formal clerkships. Data from shadowing
in surgical subspecialties suggest that early exposure may increase interest in surgical
fields and ultimately lead more students to choose surgery as a career.[4]
[5] However, not all shadowing leads to increased interest. Some data on shadowing in
the emergency department suggests that early exposure may actually decrease students'
interest in that specialty.[6]
Although preclinical shadowing opportunities in labor and delivery units (L&D) are
common, no data exist regarding the impact of participation on students' perceptions
of obstetrics and gynecology (OB/GYN). Our objective was to assess the impact of preclinical
shadowing exposure to OB/GYN on students' perceptions and career interest.
Materials and Methods
We conducted a survey of rising third-year medical students from the University of
North Carolina (UNC) who had completed their preclinical years. The study was reviewed
by the UNC Chapel Hill Office of Human Research Ethics and determined to be exempt
from further review.
A panel of subject matter experts designed a survey to assess medical student experiences
and perceptions relating to their time spent shadowing on L&D. The survey was edited
by a focus group of graduate medical trainees and then piloted by a small group of
preclinical medical students for clarity and brevity. Based on their feedback, the
survey was edited. The final survey included 2 demographic questions, 6 closed-ended
questions for those did not shadow, and 14 closed-ended questions for those who did
shadow. Students who did shadow answered questions regarding their time on L&D, such
as what they saw and who they spent time with, as well as questions about how the
experience affected their perceptions of OB/GYN. Both groups were asked about the
rationale behind their choice to shadow (or not to shadow) as well as if they would
shadow again if given the opportunity.
A paper survey was given to students during a large group session of their “transitions”
course, a class designed to prepare them for clinical years. Students were given the
paper survey upon entry to the classroom and were asked to hand them to the center
aisle prior to the start of the session. Since this session was required for all students
to attend, we assumed that the total number of students who were present was equal
to the number of students who complete the clinical years at UNC. The surveys were
anonymous, and there was no way to connect the survey back to any individual student
after it was completed.
The survey results were entered into Qualtrics software (Qualtrics, Provo, UT). Demographics
of students who participated in shadowing were compared with demographics of those
who did not. Among students who did not shadow, the rationale for not shadowing was
compared based on gender and age. Older students were defined as those over 25 years
of age. The data were analyzed using descriptive statistics. Analyses were performed
using STATA (version 13, StataCorp, College Station, TX). Common themes were analyzed
from free-text responses.
Results
Of the 136 rising third-year medical students, 119 were assigned to Chapel Hill as
their clerkship site completed the survey (response rate: 86%). Of respondents, 29%
(34) students shadowed on L&D at least once during their preclinical years. Students
who shadowed were more likely to be female (79 vs. 37%; p < 0.01). There were no differences in age or prior L&D exposure between students
who did and those who did not shadow ([Table 1]).
Table 1
Student demographics
|
Shadow, n = 34 (%)
|
No shadow, n = 85 (%)
|
p-Value
|
|
Gender
|
|
Male
|
7 (20.6)
|
54 (63.5)
|
<0.01
|
|
Female
|
27 (79.4)
|
31 (36.5)
|
|
Age (years)
|
|
20–25
|
20 (58.8)
|
43 (50.6)
|
0.5
|
|
26–30
|
13 (38.3)
|
40 (47.1)
|
|
31–35
|
0
|
1 (1.2)
|
|
> 35
|
1(2.9)
|
1 (1.2)
|
|
Previous exposure to delivery
|
7 (20.6)
|
17 (20)
|
1
|
|
Prior L&D shadowing experience
|
4 (11.8)
|
8 (9.4)
|
0.7
|
|
Would do it again if had a chance
|
34 (100)
|
39 (45.9)
|
<0.01
|
Abbreviation: L&D, labor and delivery.
Among students who did not participate in shadowing, 28% cited lack of time and 27%
cited lack of interest in OB/GYN as the reasons for not electing to shadow ([Table 2]). Among students who did shadow, the most important reason for shadowing was a desire
for more exposure to OB/GYN (44%). Many students also elected to shadow because it
“seemed fun” (Table 3). There were no differences in the rationale for shadowing based
on gender or age. The vast majority of students shadowed in the first year of medical
school (85%) and only shadowed once (88%).
Table 2
Rationale for not shadowing (n = 85)
|
Most important reason for not shadowing
|
Total students who selected this option, n (%)
|
|
Did not have time
|
24 (28)
|
|
Not interested in OB/GYN[a]
|
23 (27)
|
|
Enough exposure later
|
16 (19)
|
|
No free slots
|
14 (17)
|
|
Other
|
8 (9)
|
|
Prior shadowing experience
|
0 (0)
|
Abbreviation: OB/GYN, obstetrics and gynecology.
a Older students were more likely to not shadow because they were not interested (38.1
vs. 16.3%; p = 0.024).
Table 3
Rationale for shadowing (n = 34)
|
Most important reason for shadowing[a]
|
Total students who selected this option, n (%)
|
|
Interested in OB/GYN
|
9 (27)
|
|
Wanted more exposure
|
15 (44)
|
|
Seemed fun
|
10 (29)
|
|
Other
|
0
|
Abbreviation: OB/GYN, obstetrics and gynecology.
a No significant differences by age or gender.
Table 4
Shadowing experience (n = 34)
|
Total number of students, n (%)
|
|
Experiences[a]
|
|
Saw any delivery
|
29 (85)
|
|
Saw vaginal delivery
|
27 (79)
|
|
Saw cesarean section
|
9 (27)
|
|
Saw rounds
|
15 (44)
|
|
Saw patient in triage
|
14 (41)
|
|
Saw other
|
3 (9)
|
|
Majority of time spent with[b]
|
|
Intern
|
16 (47)
|
|
Resident
|
10 (29)
|
|
Attending students
|
8 (24)
|
a No significant differences based on gender or age.
b Older students were less likely to spend time with the attending students compared
with younger students (19 vs. 61%; p = 0.02). There were no significant differences based on gender.
Of students who did shadow, 85% saw a delivery. Of those, 79% saw a vaginal delivery,
27% saw a cesarean section, and 21% saw both (Table 4). Forty-four percent participated
in clinical rounds with the team, and 41% participated in the evaluation of a patient
in triage. Most students described spending the majority of their time with the intern,
though 29% spent the majority of their time with an upper level resident and 24% with
the attending students.
Students who did shadow overwhelmingly described the experience as worthwhile (97.1%),
with no students feeling that it was not a valuable opportunity. Eighty-two percent
of students, 71% (5/7) males and 48% (14/27) females, who shadowed thought about OB/GYN
in a more positive way as a result of their time on L&D. As a result of shadowing,
62% of students stated they were more likely to consider OB/GYN as a career, including
32% who felt they were much more likely to consider it. Students felt that the providers they worked with altered
their opinions on OB/GYN in a positive way 85% of the time. Every male who shadowed
described feeling this way. Providers impacted opinions on OB/GYN in a very positive way for 41% of students. Observing procedures was also impactful, with nearly
75% (25/34) of students noting that procedures changed their perceptions of OB/GYN
in a positive way; this included almost 30% (10/34) who felt that procedures changed
their opinions in a very positive way. The only student who described procedures impacting perceptions in
a very negative way witnessed a shoulder dystocia.
In the free-text comments (n = 12), students who did not shadow commonly requested more availability and opportunities
to shadow (3/5), saying things such as “Really wish I could have shadowed.” and “More
availability would be much appreciated.” Among those who did shadow, 71% (5/7) commented
that the experience itself was impactful to them. One student said, “I saw a twin
vaginal breech and it changed everything,” whereas another commented, “This was a
valuable experience that helped to inform my career interests.” Another student said,
“I would recommend it to anyone wanting more OB/GYN exposure or just interested in
general.”
Discussion
This study demonstrated that preclinical exposure to L&D can have a positive impact
on medical students' perceptions of OB/GYN as a specialty. We also found that the
shadowing opportunity increased students' interest in OB/GYN as a career. Students
almost unanimously found the experience worthwhile. Students overwhelmingly stated
wanting more exposure to OB/GYN as a rationale for shadowing, and only approximately
half of students who shadowed did so because of an interest in OB/GYN. Finally, nearly
half of those who did not shadow, would have if liked to if they were given the opportunity
again.
This study looks specifically at the impact of preclinical exposure on medical students'
perceptions of OB/GYN, which is poorly described previously in the literature. Most
data regarding OB/GYN as a career choice come from students after their clerkships.
Chang et al surveyed 81 students at the completion of their OB/GYN clerkship to identify
factors associated with interest in OB/GYN.[7] Having positive resident role models and feeling like part of the team were the
factors most correlated with students' interest in OB/GYN. In our study, more than
75% of students spent the majority of their time with residents and almost half rounded
with the team. Similarly, Blanchard et al surveyed 153 students matching in OB/GYN
to determine which factors impacted their career choice.[8] Among this group, third-year clerkship, fourth-year electives, and an OB/GYN mentor
were all of high importance. Again, this study did not include any mention of preclinical
exposures. Fogarty et al surveyed 10 years' worth of graduates from a single medical
school to understand factors impacting career choice.[9] This study found that exposure to an OB/GYN faculty in a small group learning environment
in the second year was significantly associated with OB/GYN as a career choice. The
authors hypothesized this finding to be because of a curricular change in the second
year to a system-based small group oriented curriculum during the study period. This
finding suggests that any exposure, clinical or nonclinical, can be impactful in career
choice.
Our study's primary strength is that it addresses a very commonly offered experience
(L&D shadowing), but minimal data exist regarding its impact on students. Our survey
was designed by subject-matter experts, edited by graduate medical trainees, and piloted
prior to implementation to avoid unclear or ineffective questions. Additionally, by
using a paper survey at a required course session, we were able to obtain a very high
response rate. Finally, the survey was anonymous and administered prior to starting
any clerkships, minimizing student concern regarding effects on grades or desire to
inflate responses. However, there are weaknesses as well. Our study's primary weakness
is that the survey was administered up to 2 years after the shadowing experiences,
increasing the risk of recall bias. While our sample size was small, to our knowledge,
it represents the largest study to date of students who have shadowed on L&D during
their preclinical years. We must also note that UNC has three sites for the clinical
years, and we only surveyed the students who were completing their clinical years
at UNC. This does represent more than 75% of all rising third-year students. Finally,
no validated tool regarding shadowing experiences exists; thus, we needed to develop
and use a nonvalidated instrument.
Despite these limitations, this study highlights three elements related to L&D shadowing
programs. First, shadowing appears to increase interest in OB/GYN as a career. Second,
students almost universally felt the experience was worthwhile. Finally, many students
elected to shadow not because of an interest in a career in our field but because
they desired more exposure. In the future, prospective data in the form of a survey
before shadowing, after shadowing, and 3 to 6 months after shadowing might help to
assess the impact of shadowing on perceptions of OB/GYN and career choice on an individual
level directly. These data suggest that shadowing on L&D impacts students' perceptions
on OB/GYN in a positive way and could be a motivation for OB/GYN departments to continue
to invest in these sorts of preclinical experiences.
