INTRODUCTION

New educational directions are being pursued in many medicalschools. They tend to involve the definition of a core curricu-lum, allow time for study in depth, promote greater diversity,and pay greater attention to continuing professional develop-ment.1 At the same time, changes in the delivery of surgical careand the nature of ‘general surgery’ have created the need for analternative to mandatory attachments to general surgery units.There are also demands for a closer match between what istaught in medical schools, postgraduate training, and therequirements of the workplace.2,3

It is evident that there is a need to dissect out the components ofsurgical practice that have relevance for medical students. That isthe target of the present article; and, although in many ways it trulyemphasizes general aspects of surgery, to avoid confusion wehave used the heading ‘generic surgery’.

SURGEONS AS EDUCATORS

The role of the surgeon as teacher has been a time-honoured tra-dition in the field of surgery. If this is to be maintained then sur-geons need to adapt to a new role.4 Table 1 outlines some of thechanges that are now required of surgical educators. It is evidentthat most will find that this is a difficult task and it will not beachieved without effort.

Principles of adult education

It is necessary to create an environment in which students can learneffectively and efficiently, and this requires teachers that aremore than just experts in their fields of endeavour.5 They must alsounderstand how adults learn (Table 2). This is importantbecause adults only engage in learning when there is a clearlydefined purpose in mind. There is a vast difference between asenior medical student who is practising as many long and short‘cases’ as possible, while attempting to memorize a surgicaltextbook, and a student who is aiming to become a competentintern. The difference relates to role playing versus taking

control of one’s own destiny.It is impossible to progress with confidence in the absence of

trustworthy feedback. Table 3 outlines a powerful method of cri-tiquing a performance. Peyton has discussed this type of approach atsome length and stresses the need to avoid launching into a negative‘what went wrong?’ approach by adopting a much more positive attitude aimed at consolidation and improvement.6 In this way,‘positive and immediate feedback act as a powerful extrinsic moti-vation for the learner’.

Teaching with patients

Clinical teaching has traditionally been centred around inpatientward rounds. As discussed earlier in this review, however, this ischanging in line with the changes that are occurring in thehealth-care system. But regardless of the nature of the clinicalenvironment it is important that students learn in the ‘realworld’.

The clinical milieu offers a rich mix of material that should bedissected and the components reflected upon in detail. Besideslearning the techniques of taking a history and performing aphysical examination, there is now emphasis upon communicationskills, the ability to function as a member of a team, ethics,problem solving, evidence-based decision making, the ordering andinterpretation of tests, and the attainment of competence in basicprocedures. This type of active approach contrasts with studentstagging along at the end of ‘grand rounds’ or being lectured to ina seminar room.

One of the few drawbacks of patient-based teaching is that it isopportunistic. Although many generic issues can be approached ina meaningful manner on any group of patients, there is a core ofessential material that may be missed if teaching is restricted topatients within large hospitals. Examples include skin lesions,‘lumps and bumps’, and hernias. For this reason clinical experiencemay need to be supplemented by controlled experiences in skillscentres. The Structured Clinical Instruction Module (SCIM) hasbeen designed to provide students with a structured approach to clinical skills on a single clinical topic.7 It is an alternative to lecturesplus conventional student exposure to patients.

It is difficult for busy surgeons to attend teaching workshops andbecome re-trained as educators. Andriole et al. evaluatedwhether a 1-day workshop could alter the way that practisingsurgeons teach.8 The workshop consisted of five sections withsmall group discussions and opportunities for practical application

ANZ J. Surg. (2001) 71, 108–113

SURGICAL EDUCATION

THE DEVELOPMENT OF UNDERGRADUATE CURRICULA INSURGERY: II. GENERIC SURGERY

JEFFREY M. HAMDORF AND JOHN C. HALL

Department of Surgery, University of Western Australia, Perth, Western Australia, Australia

The present paper focuses upon the issues in curricular reform that have specific relevance for surgeons. A central theme is that, takinginto account the dual diminution of general surgery and large central teaching hospitals, there is a need to have a clear vision of whatshould be included in surgical curricula and how we can adjust to new methods of teaching and learning.

Key words: curriculum, medical education, medical students, surgery, teaching.

Correspondence: Professor J. C. Hall, University Department of Surgery,Royal Perth Hospital, Wellington Street, Perth, WA 6000, Australia.Email: jchall@cyllene.uwa.edu.au

Accepted for publication 26 September 2000.

of participants’ knowledge. Although the course changed theparticipants’ perceptions of their role as teachers, longer termstudies are needed to determine whether this improves theireffectiveness as teachers. Similar workshops within Australasiahave been well received and there is a need to include our registrarsin these efforts to enhance their skills as trainers of junior staff.9

Leadership

In 1993 the American College of Surgeons sponsored a course enti-tled ‘Surgeons as educators’.10 It was aimed at providing academicsurgeons with the knowledge and skills necessary to enhancesurgical education. Important areas were perceived to be admin-istration, curricular development, teaching and evaluation.Within 6 months of returning from the course, more than one-halfof the graduates initiated actions related to curricular develop-ment, teaching strategies or educational administration.11 One-third or more of the graduates modified their performance andprogramme evaluation systems. The retreat environment and thelength of the programme helped attendees to become immersedduring this ‘protected time’, to analyse strengths and weak-nesses of their programmes and devise achievable plans toimprove their abilities as educators and the effectiveness of theirprogrammes.

The Surgical Royal Colleges in the British Isles have undertakena shift from being examination and certification bodies tobecoming educational bodies. This has placed greater emphasis onthe need for skills in course planning, curricular design, staffdevelopment and a range of practical teaching techniques.12

Similar changes are occurring within Australasia and it isbecoming apparent that the same educational principles apply toboth undergraduate and postgraduate surgical education. It isnecessary for surgeons to demonstrate leadership in these areasbecause, among other things, role models and mentors play animportant role in career choices and the methods of careerdevelopment.

What happens in medical students’ training has implications forthe Royal Australasian College of Surgeons. Bogduk delivered aplenary lecture at the Annual Scientific Meeting of the RoyalAustralasian College of Surgeons in 1996.13 It was argued thatcourses for medical students in Australia have evolved awayfrom exposing students to rigorous surgical basic sciences. Inorder to fill the gap left between undergraduate teaching and the

Part I examinations, he argued that the College should become aneducational institution by developing objectives and providingresources that enable candidates to learn not only what is pertinentto surgical basic training, but also how to learn it and why. The callis for the College to take a leading role in education of surgicaltrainees.

A group from McGill University School of Medicine hasexplored the relationship between exposure to clinical rolemodels during medical school and the students’ choice of clinicalfield for residency training.14 Ninety per cent of graduating studentshad identified a role model or models during medical school.Personality, clinical skills and competence, and teaching abilitywere most important in the selection of a role model, whileresearch achievements and academic position were least important.

THE PROCESS OF CHANGE

Much has been written within the non-medical literature about themanagement of change within organizations, which is some-times referred to as a re-engineering process. This topic is just asrelevant for medical schools as it is for large commercial organi-zations. Table 4 lists the key steps that need to be addressedduring curricular reform.15 All agree that the managementprocesses involved in such tasks are difficult and more oftenthan not the final outcome is less than the desired objective.This is especially so if adequate funds are not made available.

In this day and age it is impossible to achieve effective curricularreform without investing in two resource-intense areas: informationtechnology and an ‘education office’. The first requires littlediscussion because all tertiary students now need access tointranet and Internet facilities. The need for an ‘educationoffice’, however, may not be quite so evident.

In the past most of the time devoted to medical education wasoccupied by teaching; the organization was done by departmentalsecretaries and little time was spent on the evaluation andimprovement of courses. Academic departments have tended tohave a ‘research first’ approach and this has pushed teachinginto the background. A further issue for surgeons is an orientationtowards clinical services that consumes so much of our time. It isnow impossible to achieve effective change merely by grafting neweducational activities onto academic departments unless they are

UNDERGRADUATE COURSES IN SURGERY 109

Table 1. The shifting role of teachers

Traditional Future

Focus on teachers Focus on students and teachersStudents subservient A partnershipDidactic teaching Facilitator of learningEmphasis on what is taught Emphasis on what is learnt

Table 2. The characteristics of adult learning

Clearly defined objectivesVoluntary participationAn active processA desire for feedbackA need for reflection

Table 3. The process of feedback

What do you think went well?What do others in the group think went well?How could your performance be improved?What do others in the group think could be improved?

Table 4. Some appropriate steps in the process of curricularreform

Audit current effortsInvolve all in the processIdentify changes that need to occurGain agreement about the direction of changeSecure the necessary resources and personnelDefine and get agreement about specific changesImplement change at an acceptable rateMonitor progress with reference to the defined objectives

provided with an adequate infrastructure. Because curricularchange is coordinated at a faculty level, this teaching infrastructureoften takes the form of shared resources within an educationaloffice.

It is important that surgeons are effective participants in theprocess of change. This is because it is impossible to achieve acompetent curriculum unless there is a coordinated approachthat is overseen at a faculty level, and standing aside from suchprocesses is not an effective strategy for the appropriateadvancement of surgery.

Surgeons should not view curricular change as a territorialissue. Schwartz et al. have discussed their experience of curricularreview in the Otago Medical School.16 Departments with autonomywere opposed to any move to set up a central committee withthe authority to scrutinize the preparation of examinations, nomatter what the educational advantage might have been. At thesame time, departments were surprisingly responsive to suggestionsabout educationally sound assessment practices, as long as thosesuggestions were in the department’s own interests.

The changes being implemented in medical schools will influ-ence postgraduate surgical training. Of particular concern is theplace of the basic medical sciences, and particularly ofanatomy.17,18 Factors that leave today’s medical graduates with apoor knowledge of anatomy include the reorganization of disci-pline-based departments into large units of biomedical science; thereduction in time allotted to anatomy, particularly to dissection bystudents; the development of integrated courses with multidisci-plinary examinations in which poor performance in anatomy can becompensated for by good marks in other subjects; and thedecline in faculty staff with expertise in human anatomy. It isfurther aggravated by the loss of demonstratorships available to sur-gical trainees. This deficiency is not easily remedied by the pro-posed changes in basic surgical training and is not adequatelyidentified by the examination arrangements.

METHODS AND VENUES

The principles that were outlined in our first article in thepresent series need to be linked to the delivery of surgical teaching.Emphasis is now given to some of the areas that have recently beendiscussed in that context.

Ward attachments

Surgical teaching can be offered in many specialty settings.Removal of the requirement for general surgery in clinicalattachment may lead to a more effective use of all educationalopportunities and result in broader training.19 The surgery clerkshipat the Southern Illinois University School of Medicine, whichprovides a completely integrated multidisciplinary programme,has provided an effective programme based upon subspecialtyservices as well as on general surgery.20

One of the universal certainties of curricular reform is thatevery specialty group will claim that their subject is beingunder-taught. When taken in isolation the comments appear tohave validity, but adoption of all the bids would only exacerbate theproblems that already exist in medical education. By way ofexample, Granick et al. have commented that students areoffered only a limited or sporadic experience in plastic surgery atmost medical schools.21 They believe this to be ‘unfortunatebecause all physicians need to possess the knowledge and skills toevaluate skin lesions and participate in wound management’.

Other recent comments include: ‘The education and evaluation ofresidents in oncology needs improvement’,22 ‘Medical schoolpreparation in musculoskeletal medicine is inadequate’,23 and‘More curricular time devoted to education about breast cancerscreening is needed’.24

Surgical specialties are becoming more reliant upon ambulatorycare in their teaching. In view of the unremitting trend towardambulatory care and the move of surgical teaching into theambulatory setting, the trend observed deserves consideration.Also, the use of all surgical specialties may result in greaterfreedom in providing institutional resources for the clerkship.

The need for a general training in surgery implies that thereare core areas of knowledge that are required from each of the sur-gical subspecialties.25 Surveys of subspecialty objectives canclarify educational priorities and identify areas of proficiencyand deficiency. In a study from Canada, Poenaru and Woo surveyedmedical students, surgeons and ‘family physicians’ on their per-ception of approximately 60 learning objectives related to paediatricsurgery.26 Such approaches allow for a comparison about the perceived need for knowledge within specific disciplines.

Group sizes

Clinical evaluations of junior surgery students frequently lacksufficient detail for effective formative or summative feedback.Ephgrave et al. hypothesized that this was in part due to a lack ofpersonal accountability associated with large general surgeryteams, and that altering the format to assign students to specific sur-gical faculty preceptors rather than to teams would affect theclinical evaluation products.27 One-third of the preceptors were sub-specialists. The preceptor format resulted in a greater proportion ofstudents recommended for overall clinical honours, but had noimpact on exam performance. Team format students felt theyhad too few patients, whereas twice as many preceptor students felttheir informal instruction had been less than ‘good’. Eachformat had advantages and disadvantages. They concluded that thebest results might be obtained by limiting the number of stu-dents on the general surgery teams and adding structured formativefeedback from faculty before the end of the clerkship.

Day-surgery units

Day units should play a major role in surgical education.Seabrook et al. undertook a postal survey to determine the extent andnature of medical education in day-surgery units in the UnitedKingdom.28 Of the 227 units which replied, only 45% of the unitswere being used for teaching. In 83% of these units the medical students attended only a single operating list, and only 7% of theunits took the students for more than 1 day per week. Thesefigures indicate that medical students receive very limited teachingin day-surgery units.

Patients attending day-surgery units are a valuable resource.O’Riordan and Clark surveyed 100 consecutive short stay surgicalinpatients admitted to hospital on the day of planned operation todetermine whether they might be available for student teachingbefore surgery.29 They found that there was a median delay of 3 hbetween the completion of the medical and nursing procedures andthe departure of the patient for the operating theatre. All but 2% ofthe patients said that they would agree in principle to participate instudent teaching.

Day-surgery centres can be used successfully to teach medical stu-dents. A programme for teaching medical students in day-surgery

110 HAMDORF AND HALL

units has been established at the University of Adelaide.30 Theinstigators have noted that this initiative has been accepted by all ofthe stakeholders and, in an Australian study, staff from a dayward did not perceive that students had significantly detractedfrom the overall efficiency of the unit.31 An unexpected findingwas the substantial contribution that students made to quality ofpatient care. It was perceived that the students had significantgains in both knowledge and skills. The results of this programmemirrors that experienced in the day-surgery unit at the King’sCollege School of Medicine in London.32

Perioperative care

Many learning opportunities arise during the perioperativeperiod (Table 5). It is important to appreciate that the issuestend to be shared between all types of surgery and the suitability ofa particular unit is most dependent upon the quality of the teachingrather than the nature of the clinical material.

There is a need for good communication skills during theperioperative period. For example, Perkins et al. have evaluated theinteractional skills of surgical trainees when breaking bad news andpreparing patients for major procedures.33 The results were dis-appointing and it was concluded that there is a need to teachinteractional skills as part of surgical training. Such skillsinclude active listening, empathic responses, probing strategies,open-ended questions, techniques designed to improve patientrecall and the promotion of compliance with therapy.

Urgent care

Some medical schools are developing a collaborative approach tourgent care that extends from basic first aid courses during the startof the course through to emergency medicine attachmentsduring the clinical years. Surgical attachments often include elements of such programmes, and there may be strong inputsfrom intensive care units and departments of anaesthesia. This pro-gressive accumulation of skills in urgent care should ensurebasic competence in resuscitation before the start of the intern year.

Butler et al. have assessed the knowledge and attitudes offourth-year students to injury control.34 The authors conducted across-sectional survey of six medical schools in the USA. The stu-dents were unable to answer correctly half of the questionstesting injury-related knowledge. They also rated medical problemsas being more important and more preventable than injury pro-blems, and they felt more comfortable asking their patientsabout risk factors for medical problems. Injury control issueswere encountered by the students least often on rotations in psy-chiatry (23%) and surgery (14%). The authors concluded thatinjury control has limited coverage in surgical curricula and, as aresult, students have little understanding of the principles andbenefits of injury control.

Manual skills

It is essential that interns have competence in basic proce-dures.35 There has been an historical neglect of the teaching ofsimple surgical skills to medical students in a structured fashion, butattitudes are changing. There is now the prospect of the craftworkshops that are being generated for surgical trainees to influ-ence the way that medical students acquire basic proceduralskills. This has been facilitated by the development of a range ofsimulated tissues that substantially increases levels of confi-dence and competence to carry out minor procedures.36

A number of studies has defined the types of procedural skills thatneed to be held by interns.37–39 Table 6 provides a list of candidateprocedures. Medical students want teaching that is relevant toclinical care. When Ward et al. surveyed 205 medical studentsand junior doctors in Leicester they found that they valued teachingin venepuncture, intravenous cannulation and urinary catheteri-zation.40 In 1983 Lawrence et al. reported a survey of residents intraining, physicians in practice and surgical educators.41 Theygraded history taking and physical examination, gowning andsuture removal as very important; while other skills, such asinsertion of the Swan–Ganz catheter and abdominal paracentesis,were thought to be less important. Physicians thought asepticgowning and removal of sutures were important tasks.

Lossing and Groetzsch performed a prospective controlledtrial of teaching basic surgical skills to fourth-year medical studentsat the University of Toronto.42 The skills were scrubbing,gowning, gloving, instrument handling (right and left hand),suturing, cutting and stapling. The investigators noted that suchteaching has often been delegated to junior house staff and earlybad habits are difficult to unlearn in postgraduate training. Thestudy supported the use of a simulation appendectomy model toteach and test the skills at five stations.

Minor surgical procedures form an important part of manyareas of clinical practice, and this is especially so for generalpractice. Thompson et al. have used a postal questionnaire toassess the attitudes towards operative practice in minor surgerygeneral practitioners in the Scottish Highlands and WesternIsles.43 Teaching in minor surgery had been received by 74% ofgeneral practitioners yet 43% considered their training to beinadequate. Although confident to suture simple wounds orexcise skin lesions from the trunk, significantly fewer were con-fident to excise such lesions from the face. From 86% of generalpractitioners who wished to attend a training course on minorsurgery, 62% would prefer to be taught on patients and 36% on arealistic skin simulator. Assessment of technical competence by ahospital consultant was considered desirable by more than one-half.

UNDERGRADUATE COURSES IN SURGERY 111

Table 5. The components of perioperative care

AnaesthesiaObtaining consentCommunicating with patients and relativesProphylaxis against adverse eventsEthical issues (e.g. futile care)Paraclinical servicesOrdering and interpreting testsTheatre etiquette

Table 6. Some examples of manual skills that may be appropriate formedical students

Sterile gowningEndotracheal intubationApplication of a forearm castBasic bandaging techniquesVenepunctureInsertion of an intravenous cannulaConnection of an intravenous lineSuturing a simple skin lacerationRemoval of suturesInsertion of a urinary catheterInsertion of a chest tube

Manual skills combine two functions: the intellectual exercise ofdecision making and more mechanical processes or dexterity.44 Theability to perform a procedure is a double-edged weapon and it isimportant that the initial teaching of manual skills is accompaniedby information about their appropriate application. In addition,skills workshops have the capacity to continually stress the need forsafe practices, especially those that are aimed at the prevention ofthe spread of blood-borne infections.

Learning materials

Medical schools need to adapt their teaching in response to thereduction in inpatient and outpatient services and the increase inday-surgery and community-based care.45 Although the desire tocoordinate care across all sites is strong, and finds expression indocuments produced by administrators in terms such as ‘seamlesscare’ and ‘hospitals without walls’, the reality is that there are fewhealth-care systems that effectively coalesce these services in amanner that facilitates medical education.

There is a particular need to extend teaching into privatemedical facilities.46 After all, graduates from Australasianmedical schools tend to spend the greater part of their working livesin the private sector. The attainment of experience based purelyupon public hospitals is educationally inappropriate because itfails to provide an appropriate diversity of experiences.

A reduction in the availability of suitable inpatients has led to someinnovative programmes. For example, Delbridge’s group fromRoyal North Shore Hospital has used models (surrogate patients) toteach normal physical examination skills to junior medical stu-dents.47 This was thought to be ‘an effective way of deliveringquality clinical training to a group of junior medical students in anenvironment where access to good teaching material is becomingincreasingly difficult’. Others have developed clinical skillsresource centres that use a variety of standardized approaches to sup-plement more conventional forms of clinical teaching.48

Participation in outpatient surgery clinics needs to be accom-panied by specific objectives and appropriate tools used tomeasure their successful achievement.49 Follow-up patients,who often have complex problems, rarely generate a usefultraining episode.50

Study guides are required to facilitate self-directed learning.There is a need for something beyond logbooks, which are oflimited value unless they are accompanied by frequent feed-back.51 It has been argued that reflective journals and learning port-folios promote the attitudes that are likely to encourage thelifelong learning necessary for doctors and to foster the develop-ment of ‘reflective practitioners’ who can modify their practice inrelation to experience.52

The use of learning journals offers a means of achieving some ofthe more important goals of problem-based learning,53 particu-larly those requiring students to reflect upon and evaluate theirexperiences. When effectively integrated with problem-basedlearning, journals have several functions: to formalize reflection; tobe an outlet for personal feeling; to be an opportunity for feed-back about a student’s progress and about the course; to provide thestudent with a summary of the year’s work; and a means wherebystudents and teachers gain insight into the learning process.

CONCLUSION

This article has provided an overview of issues that are con-fronting surgeons who participate in medical education. The

reorganization of health services presents new opportunities andchallenges for surgical education, and many of the issues thathave been raised in the present article are relevant to postgraduatesurgical education. The challenge is to ensure that important tra-ditional skills are retained within courses while at the same timeaccommodating new and worthwhile innovations. The finalarticle in the present series concerns the process of assessment.

ACKNOWLEDGEMENTS

We would like to thank Dr Tony Celenza, Mr Paul Norman, MrCameron Platell, Assoc. Prof. Michael Stacey, Mr Allan Wang andMs Carleen Ellis who have each made significant contributions tothe development of the surgical curriculum in the University ofWestern Australia. In turn, we all express gratitude to the studentsand teachers who have so willingly participated in this process.

REFERENCES1. Davis D, Thompson M, Oxman A, Haynes R. Evidence for the

effectiveness of CME. A review of 50 randomised controlledtrials. JAMA 1992; 268: 1111–17.

2. Calman K, Temple J, Naysmith R, Cairncross R, Bennett S.Reforming higher specialist training in the UK: A step alongthe continuum of medical education. Med. Educ. 1999; 33:28–33.

3. General Medical Council. The New Doctor. London: GeneralMedical Council, 1998.

4. Dunnington GL, DaRosa D. A prospective randomized trial of aresidents-as-teachers training program. Acad. Med. 1998; 73:696–700.

5. Rodgers A. Teaching Adults. Buckingham: Open UniversityPress, 1992.

6. Peyton JWR. Teaching and Learning in Medical Practice.Heronsgate, Rickmansworth: Manticore Europe Limited, 1998.

7. Blue AV, Stratton TD, Plymale M, DeGnore LT, Schwartz RW,Sloan DA. The effectiveness of the structured clinical instructionmodule. Am. J. Surg. 1998; 176: 67–70.

8. Andriole DA, Evans SRT, Foy HM, Atnip RG, Mancino AT.Can a one-day workshop alter surgeons’ teaching practices?Am. J. Surg. 1998; 175: 518–20.

9. Hargreaves DH. Registrars as trainers: The use of questioning tech-niques in on-the-job training. Ann. R. Coll. Surg. Engl. 1998;80: 10–13.

10. DaRosa DA, Folse JR, Sachdeva AK, Dunnington GL, Reznick R.Description and results of a needs assessment in preparation for the‘Surgeons as educators’ course. Am. J. Surg. 1995; 169: 410–13.

11. DaRosa DA, Folse JR, Reznick RK, Dunnington GL, SachdevaAK. Description and evaluation of the Surgeons as Educatorscourse. J. Am. Coll. Surg. 1996; 183: 499–505.

12. Bligh J. Curriculum design revisited. Med. Educ. 1999; 33:82–5.

13. Bogduk N. The College as an educational institution. Aust. N.Z. J.Surg. 1997; 67: 679–81.

14. Wright S, Wong A, Newill C. The impact of role models onmedical students. J. Gen. Intern. Med. 1997; 12: 53–6.

15. Freeman R, Lewis R. Planning and Implementing Assessment.London: Kogan Page, 1998.

16. Schwartz PL, Heath CJ, Egan AG. The Art of the Possible.Dunedin: University of Otago Press, 1994.

17. Raftery AT. Basic surgical training. 1: Postgraduate surgicalexaminations in the UK and Ireland. Clin. Anat. 1996; 9:163–6.

18. Willan P. Basic surgical training. 2: Interactions with the under-graduate medical curriculum. Clin. Anat. 1996; 9: 167–70.

112 HAMDORF AND HALL

UNDERGRADUATE COURSES IN SURGERY 113

19. Ko CY, Whang EE, Karamanoukian R, Longmire WP, McFaddenDW. What is the best method of surgical training? A report ofAmerica’s leading senior surgeons. Arch. Surg. 1998; 133:900–5.

20. Poenaru D, Davidson L, Donnely M, Tekain A. Is a mandatorygeneral surgery rotation necessary in the surgical clerkship?Am. J. Surg. 1998; 175: 515–17.

21. Granick MS, Blair PG, Sachdeva AK. A new educational role forplastic surgery in the fourth year of medical school. Plast.Reconstr. Surg. 1999; 103: 1523–8.

22. Sloan DA, Donnelly MB, Schwartz RW et al. Measuring theability of residents to manage oncologic problems. J. Surg.Oncol. 1997; 64: 135–42.

23. Freedman KB, Bernstein J. The adequacy of medical schooleducation in musculoskeletal medicine. J. Bone Joint Surg. Am.1998; 80: 1421–7.

24. Kann PE, Lane DS. Breast cancer screening knowledge andskills of students upon entering and exiting a medical school.Acad. Med. 1998; 73: 904–6.

25. Curet MJ, DaRosa D, Mennin S. University and practice-basedphysicians’ input on the content of a surgical curriculum. Am. J.Surg. 1999; 178: 78–84.

26. Poenaru D, Woo M. Undergraduate pediatric surgery objec-tives: Goal and reality. J. Pediatr. Surg. 1998; 33: 852–5.

27. Ephgrave KS, Ferguson K, Kreiter C, Goodwin B. Team-basedversus preceptor-based assignment of junior surgery students.Am. J. Surg. 1997; 173: 333–7.

28. Seabrook MA, Lawson M, Baskerville PA. Teaching and learningin day surgery units: A UK survey. Med. Educ. 1997; 31: 105–8.

29. O’Riordan DC, Clark CL. Potential availability of patients in ashort stay ward for medical student teaching. Ann. R. Coll.Surg. Engl. 1997; 79: 15–16.

30. O’Driscoll MC, Rudkin GE, Carty VM. Day surgery: Teaching thenext generation. Med. Educ. 1998; 32: 390–5.

31. Rudkin GE, O’Driscoll MC, Carty VM. Does a teaching pro-gramme in day surgery impact on efficiency and quality ofcare? Aust. N.Z. J. Surg. 1997; 67: 883–7.

32. Seabrook MA, Lawson M, Woodfield S, Baskerville PA.Undergraduate teaching in a day surgery unit: A 2-year evaluation.Med. Educ. 1998; 32: 298–303.

33. Perkins JJ, Sanson-Fisher RW, Anselilne P, Gillespie WJ,Lowe A. A preliminary exploration of the interactional skills oftrainee surgeons. Aust. N.Z. J. Surg. 1998; 68: 670–4.

34. Butler RN, Todd KH, Kellermann AL et al. Injury-control education in six U.S. medical schools. Acad. Med. 1998; 73:524–8.

35. McMahon DJ, Chen S, MacLellan DG. Formal teaching ofbasic surgical skills. Aust. N.Z. J. Surg. 1995; 65: 607–9.

36. Tissier J, Rink E. Evaluation of minor surgery courses forgeneral practitioners. Med. Educ. 1996; 30: 333–8.

37. Bullock G, Kovacs G, Macdonald K, Story BA. Evaluating pro-cedural skills competence: Inter-rater reliability of expert andnon-expert observers. Acad. Med. 1999; 74: 76–8.

38. Martin M, Vashisht B, Frezza E et al. Competency-basedinstruction in critical invasive skills improves both resident performance and patient safety. Surgery 1998; 124: 313–17.

39. Nasmith L, Franco ED. Minor surgical procedures. Facultydevelopment workshop. Can. Fam. Physician 1997; 43:715–18.

40. Ward B, Moody G, Mayberry JF. The views of medical stu-dents and junior doctors on pre-graduate clinical teaching. Post-grad. Med. J. 1997; 73: 723–5.

41. Lawrence PF, Alexander RH, Bell RM et al. Determining thecontent of a surgical curriculum. Surgery 1983; 94: 309–17.

42. Lossing A, Groetzsch G. A prospective controlled trial ofteaching basic surgical skills with 4th year medical students.Med. Teach. 1992; 14: 49–52.

43. Thompson AM, Park KGM, Kelly DR, MacNamara I, MunroA. Training for minor surgery in general practice: Is it ade-quate? J. R. Coll. Surg. Edinb. 1997; 42: 89–91.

44. Spencer FC. Teaching and measuring surgical techniques: Thetechnical evaluation of competence. Bull. Am. Coll. Surg. 1978; 63:9–12.

45. Lennox A, Pederson S. Development and evaluation of a com-munity-based, multi-agency course for medical students:Descriptive survey. BMJ 1998; 316: 596–9.

46. Hirst G, Rotem A, Arnold T, Moss D. Report of a workshop toreview urological training in Australasia. Aust. N.Z. J. Surg.1995; 65: 273–7.

47. Hardman DT, Patel MI, Delbridge L. Teaching normal physicalexamination in a large-group interactive using artists’ models. Aust.N.Z. J. Surg. 1997; 67: 468–71.

48. Bradley P, Bligh J. One year’s experience with a clinical skillsresource centre. Med. Educ. 1999; 33: 114–20.

49. Neumayer L, McNamara RM, Dayton M, Kim B. Does volume ofpatients seen in an outpatient setting impact test scores? Am. J.Surg. 1998; 175: 511–14.

50. Raine C, Crofts TJ, Griffiths JM, Aitken RJ. Training in surgicaloutpatients. Ann. R. Coll. Surg. Engl. 1996; 78: 59–61.

51. Jolly B. Clinical logbooks: Recording clinical experiences may notbe enough. Med. Educ. 1999; 33: 86–8.

52. Snadden D, Thomas M. The use of portfolio learning inmedical education. Med. Teach. 1998; 20: 192–9.

53. Wetherell J, Mullins G. The use of student journals in problem-based learning. Med. Educ. 1996; 30: 105–11.