As societal expectations evolve and the cost of veterinary education rises, pressure has been increasing to clarify expected outcomes for veterinary students and ensure those outcomes are achieved.1,2 At the same time, the profession has been evaluating what defines competence in veterinary medicine,3–12 with several studies13–16 specifically focusing on stakeholder satisfaction with the abilities of new veterinary college graduates.
To develop meaningful outcome measures and design an effective veterinary curriculum to achieve those outcomes, academicians must understand what is expected of new graduates. Several previous studies4–11 have attempted to clarify these expectations. As a foundation for assessing and enhancing veterinary college curricula, these studies have been helpful, but they lack quantifiable parameters to gauge outcomes for individual students and programs. Most notably, there is a need to define what combination of skills, knowledge, and clinical reasoning is required for new graduates to adequately care for patients and clients.
On top of this, employers, students, and academic faculty may have different perspectives on the abilities and proficiency expected of new graduates.5–7,15,17–19 In a United Kingdom study,19 for example, students and veterinarians differed considerably in their opinions as to whether new veterinary graduates should be expected to perform an OVH in a dog without assistance. These differences of opinion have important implications for curriculum development, assessment of students, and new graduate morale. A shared understanding of the expectations of new graduates is important for all stakeholders. Importantly, veterinary students need to understand what is expected of them so they can gauge their own progress and readiness for practice and determine the value of their education.
Surgical and diagnostic procedures lend themselves to qualitative and quantitative assessments of the abilities of new veterinary graduates and to defining expected outcomes. In the past 25 years, 2 of the most commonly reported educational deficits have been ability to perform various surgical procedures and confidence in one's surgical abilities,15,20,21 indicating a need to focus on these skills. Inexperienced practitioners who lack confidence and surgical skill may experience distress, which in turn may impact judgment, decision making, and communication, such that clients or patients are harmed.22–24 Medical education scholars have argued that the goal should be to ensure that trainees reach the autonomous phase of learning, allowing them to focus on additional tasks related to the context of the case or the environment.25–28
The present study was designed to assess, through use of a survey, expectations of a broad cross section of stakeholders regarding the ability of new veterinary graduates to perform various diagnostic and surgical procedures. The diagnostic and surgical procedures included in the survey represented a variety of previously identified foundational clinical skills.3–11 Efficiency and proficiency in performing each of the procedures were used as the primary metrics because these metrics are relatively straightforward to communicate and understand, have direct implications for a new graduate's success in practice, and have been previously cited in calls for curricular reform in veterinary1 and human medicine.27 Efficiency is important economically and for quality patient care. For example, prolonged anesthetic time is costly and increases the likelihood of complications.29,30 Proficiency reflects the ability of new graduates to perform independently, which matters because time spent mentoring and observing new graduates while they perform basic procedures means there will be less time available to treat other cases or to mentor new graduates in more complex procedures or business management.
Materials and Methods
The study consisted of a cross-sectional survey of veterinary students, faculty members, recent graduates (ie, individuals who had graduated in the 2 previous years), and general practitioners who were at or had graduated from AVMA COE–accredited CVMs in the United States and Caribbean. The project was determined by the Washington State University Institutional Review Board to be exempt from review. The survey instrument was evaluated by individuals from the Association of American Veterinary Medical Colleges, AVMA, and Student AVMA for suitability.
In May 2013, a link to the survey was emailed to all veterinary students (ie, students in the classes of 2013, 2014, 2015, and 2016; n = 11,474) and faculty members involved in clinical instruction (1,275) at 30 of the 32 AVMA COE–accredited CVMs in the United States and Caribbean (2 CVMs did not participate because of limitations on internal distribution of outside emails). In addition, the survey link was emailed to 500 recent graduates (ie, individuals who had graduated in 2011 or 2012 from an AVMA COE–accredited CVM in the United States or Caribbean) living in the United States randomly selected from the AVMA member database and to 2,500 veterinary practitioners randomly selected from the AVMA member database who graduated in 2010 or before, were living in the United States, and had graduated from an AVMA COE–accredited CVM in the United States or Caribbean.
The survey was developed and administered with standard software.a Respondents were presented a list of 8 diagnostic procedures (FNA of a subcutaneous mass, cutaneous punch biopsy, ultrasound-guided liver biopsy, abdominocentesis, arthrocentesis, thoracocentesis, cystocentesis, and performing hand ties with suture material) and asked to indicate (on a scale from 0 to 4, where 0 = I expect no conceptual working knowledge of the procedure; 1 = I expect a new graduate to understand the concept but not be able to execute the procedure; 2 = I expect a new graduate to understand the concept and perform the procedure under guidance; 3 = I expect a new graduate to understand the concept and be able to perform the procedure, but lack fluidity; and 4 = I expect a new graduate to be able to perform the procedure proficiently) how proficient they expected a new graduate, on his or her first day of practice, to be in each procedure. Similarly, respondents were presented a list of 8 surgical procedures (elective castration of a healthy 6-month-old dog; elective OVH in a healthy 6-month-old dog; enucleation of the right eye because of glaucoma in an otherwise healthy 10-year-old dog; removal of a freely movable, benign, 4-cm-diameter subcutaneous mass from an otherwise healthy 9-year-old cat; gastric foreign body removal in an otherwise healthy 12-month-old dog; repair of a 2-hour-old, full-thickness, 2-cm-long upper eyelid laceration in a 6-year-old horse; repair of a 1-hour-old, 10 × 10-cm cutaneous wound that had resulted in a ventrally hanging triangular flap with smooth tissue margins over the pectoral muscles of a 1-year-old horse; and emergency cesarean section in a 5-year-old cow that had been in stage 2 labor for 3 hours) and asked to indicate how long (from 0 to 240 minutes) they would expect a new graduate, on his or her first day of practice, to take to complete the procedure and the degree of independence (on a scale from 0 to 4, where 0 = I do not expect a new graduate to perform the procedure; 1 = I do not expect a new graduate to perform the procedure unless fully supervised by a more experienced veterinarian; 2 = I expect a new graduate to perform the procedure with an experienced veterinarian checking major steps and with all complications handled by the experienced veterinarian; 3 = I expect a new graduate to perform the procedure unsupervised unless complications arise; and 4 = I expect a new graduate to perform the procedure unsupervised, including handling common complications) they would expect a new graduate to have when performing the procedure. Open-response text boxes were also provided to elicit respondents' opinions on specific areas of supervision required for each procedure.
Demographic data collected from respondents varied by subgroup. Students were asked to indicate their anticipated year of graduation, the CVM they were attending, and their anticipated career path following graduation. Recent graduates were asked to indicate their year of graduation, the CVM they had attended, and their current career path. Faculty members were asked to indicate their area of clinical focus and the percentage of time involved in clinical practice. Practitioners were asked to indicate their primary area of species focus, the CVM they had attended, whether they owned the practice where they worked, and their experience working with new graduates and students. Respondents were also given the opportunity to suggest additional diagnostic and surgical procedures to which students should be exposed.
A preliminary email (students and faculty members) or postcard (recent graduates and practitioners) was sent 2 weeks before the survey opened alerting participants to the purpose of the survey and the day it would open and describing the incentives offered for their participation. On the day the survey opened, a second email or postcard was sent providing a link to the online survey. The survey remained open for 3 months, with reminders sent to nonresponders after 1 and 2 months. Incentives for participation consisted of AVMA annual convention registration for faculty members, recent graduates, and practitioners and retail gift cards for veterinary students, with winners selected by random draw.
To avoid context effects, the survey software randomized the order with which the various procedures were presented to participants. Filter questions were used in the participant demographic section to skip questions not relevant to specific respondents and to assist in validation of results.
Data analysis
For each of the 4 respondent subgroups (students, faculty members, recent graduates, and general practitioners), responses regarding proficiency for each of the 8 diagnostic procedures and independence for each of the 8 surgical procedures were summarized as stacked bar plots. Responses for time to complete each of the 8 surgical procedures were summarized as box plots. A 1-way Kruskal-Wallis test was used to check for heterogeneity in responses among respondent subgroups. To control for multiple comparisons, values of P ≤ 0.001 were considered significant.
Open-text responses regarding specific areas of supervision required for each of the 8 surgical procedures were evaluated by means of thematic analysis. In short, all responses were gathered and sequentially examined to identify themes related to areas that required supervision. As themes were created, the remaining responses were compared with those themes to determine whether they were the same or different, and new themes were created for any responses that did not fit into existing themes until all responses were represented. Once themes were determined, the total number of responses for each respondent subgroup was determined by means of manual counting, along with percentages of respondents providing each response. Suggested additional diagnostic and surgical procedures to which students should be exposed were compiled.
Results
The response rate was 9% (235/2,500) for practitioners, 12% (151/1,275) for faculty members, 14% (70/500) for recent graduates, and 15% (1,731/11,474) for students. Students from all 30 CVMs to which the survey was sent responded, with a mean of 56.8 respondents/CVM (range, 19 to 121 respondents/CVM). Anticipated career paths following graduation included private practice (1,021/1,731 [59%]), an internship (502/1,731 [29%]), a residency (104/1,731 [6%]), and “other” (104/1,731 [6%]), where “other” included military, government, public health, research, undecided, shelter medicine, and zoo medicine.
Recent graduates from 28 CVMs responded to the survey, with a mean of 2.2 respondents/CVM (range, 1 to 7 respondents/CVM). Current career path for recent graduates who responded included private practice (64/70 [91%]), a residency (1/70 [1%]), and “other” (5/70 [7%]). None of the recent graduates who responded indicated they were currently in an internship program.
Faculty members at 25 CVMs responded to the survey, with a mean of 5.4 respondents/CVM (range, 1 to 15 respondents/CVM). Of the 151 faculty members, 142 (94%) indicated that their position included some time on clinical rotations or in clinical practice. Mean amount of time in clinical practice was 59% (range, 7% to 100%). Area of clinical focus was small animal practice (82/151 [54%]), large animal practice (32/151 [21%]), mixed animal practice (14/151 [9%]), and “other” (23/151 [15%]). Open-text responses to define “other” included equine practice, radiology, anesthesiology, farm animal practice, exotic animal practice, and wildlife medicine.
Practitioners who had graduated from 31 CVMs responded to the survey, with a mean of 7.9 respondents/CVM (range, 1 to 17 respondents/CVM). Primary area of focus consisted of small animal practice (181/235 [77%]), large animal practice (11/235 [5%]), mixed animal practice (31/235 [13%]), and “other” (12/235 [5%]), where “other” included, but was not limited to, equine, dairy, exotic animal, and zoo animal practice. When asked about the extent of their experience working with students, 73 of 235 (31%) practitioners indicated that students rotated through their practice. One hundred twenty-nine (55%) practitioners indicated that they owned the practice where they worked. Of the 235 practitioners who responded, 155 (66%) indicated they would readily work with a new graduate, 49 (21%) indicated they were neutral about working with new graduates, and 19 (8%) indicated they were skeptical about working with new graduates; however, none indicated they would never work with a new graduate. Only 12 of 235 (5%) practitioners who responded indicated they had no experience working with new graduates.
All 4 respondent subgroups expected that new graduates would, on their first day in practice, be able to adequately perform an FNA of a subcutaneous mass, with 96% to 98% of respondents expecting new graduates to be able to adequately perform this procedure (ie, a score of 3 [able to perform the procedure but lack fluidity] or 4 [able to perform the procedure proficiently] on a scale from 0 to 4; Figure 1). Similarly, 93% to 97% of respondents expected new graduates to be able to adequately perform a cystocentesis. Significant differences were found among respondent subgroups with regard to proficiency expectations for FNA of a subcutaneous mass (P = 0.027), cutaneous punch biopsy (P = 0.005), cystocentesis (P = 0.001), abdominocentesis (P < 0.001), and thoracocentesis (P < 0.001). For cutaneous punch biopsy, 79% of recent graduates and 93% of faculty members expected new graduates to be able to adequately perform the procedure. For abdominocentesis and thoracocentesis, 63% and 49% of recent graduates expected new graduates to be able to adequately perform these procedures, whereas 89% and 76% of faculty members had the same expectations. Greater variability in the distribution of responses was noted for performing hand ties (P < 0.001), ultrasound-guided liver biopsy (P < 0.001), and arthrocentesis (P < 0.001). Ultrasound-guided liver biopsy was the procedure for which the lowest percentages of respondents expected proficiency, with 70% of recent graduates expecting new graduates to have no conceptual knowledge of the procedure (ie, a score of 0) or to understand the concept but not be able to execute the procedure (ie, a score of 1). Among the 4 respondent subgroups, recent graduates had the lowest expectations regarding proficiency of new graduates.
Divergent stacked bar plots representing responses of 4 stakeholder groups (general practitioners, faculty members with a clinical focus, recent graduates [ie, individuals who had graduated in the 2 previous years], and veterinary students) regarding how proficient they expected new graduates, on their first day in practice, to be when performing 8 diagnostic procedures. Proficiency was scored on a scale from 0 to 4, where 0 = I expect no conceptual working knowledge of the procedure; 1 = I expect a new graduate to understand the concept but not be able to execute the procedure; 2 = I expect a new graduate to understand the concept and perform the procedure under guidance; 3 = I expect a new graduate to understand the concept and be able to perform the procedure but lack fluidity; and 4 = I expect a new graduate to be able to perform the procedure proficiently. Percentages on the left represent respondents assigning a score of 0 or 1, percentages in the middle represent respondents assigning a score of 2, and percentages on the right represent respondents assigning a score of 3 or 4.
Citation: Journal of the American Veterinary Medical Association 251, 2; 10.2460/javma.251.2.172
For all 8 surgical procedures, responses regarding expected degree of independence varied significantly (all P ≤ 0.001) among respondent subgroups (Figure 2). Nevertheless, most respondents expected new graduates to be able to independently perform (ie, a score of 3 [perform the procedure unsupervised unless complications arise] or 4 [perform the procedure unsupervised, including handling common complications] on a scale from 0 to 4) a canine castration (82% to 94% expecting independence), feline subcutaneous mass removal (66% to 75% expecting independence), and canine OVH (65% to 89% expecting independence). Expectations were lower for canine eye enucleation (15% to 26% expecting independence), canine gastric foreign body removal (7% to 32% expecting independence), equine eyelid laceration repair (37% to 57% expecting independence), equine large wound repair (24% to 50% expecting independence), and bovine cesarean section (11% to 28% expecting independence). In general, practitioners had lower expectations regarding independence of new graduates performing these procedures than did respondents in the other subgroups.
Divergent stacked bar plots representing responses of the 4 stakeholder groups in Figure 1 regarding how independent they expected new graduates to be when performing 8 surgical procedures. Degree of independence was scored on a scale from 0 to 4, where 0 = I do not expect a new graduate to perform the procedure; 1 = I do not expect a new graduate to perform the procedure unless fully supervised by a more experienced veterinarian; 2 = I expect a new graduate to perform the procedure with an experienced veterinarian checking major steps and with all complications handled by the experienced veterinarian; 3 = I expect a new graduate to perform the procedure unsupervised unless complications arise; and 4 = I expect a new graduate to perform the procedure unsupervised, including handling common complications. See Figure 1 for key.
Citation: Journal of the American Veterinary Medical Association 251, 2; 10.2460/javma.251.2.172
Expected times for a new graduate to perform the various surgical procedures overlapped (Figure 3) but differed significantly (all P < 0.001) among subgroups. Interquartile (25th to 75th percentile) ranges were 30 to 60 minutes for expected times to perform a canine castration, feline subcutaneous mass removal, or equine eyelid laceration; 45 to 90 minutes for expected time to perform a canine OVH; 55 to 90 minutes for expected time to perform a canine eye enucleation; and 60 to 120 minutes for expected times to perform a bovine cesarean section and canine gastric foreign body removal. The greatest variability in expected time to complete the procedure was found for repair of a large equine wound, with the interquartile range extending from 45 to 105 minutes. Faculty members and students seemed to have the most difference in their time expectations overall.
Box-and-whisker plots of expected times for new graduates to complete the 8 surgical procedures in Figure 2. For each plot, the box represents the interquartile (25th to 75th percentiles) range, the horizontal line within each box represents the median, and the vertical lines extend from the interquartile range boundary to the most extreme data point that is no more than 1.5 times the interquartile range from the boundary. Those data points more than 1.5 times the interquartile range from the boundary are classified as outliers and plotted as points.
Citation: Journal of the American Veterinary Medical Association 251, 2; 10.2460/javma.251.2.172
For each of the 8 surgical procedures, at least some students indicated an expected time to completion of 240 minutes. In addition, several respondents indicated an expected time to completion of 0 minutes for some procedures. These 2 extremes were assumed to represent a belief that these were not appropriate procedures for new graduates to be performing, and for this reason, these responses were excluded from computations.
Not all survey participants responded to the open-ended question on specific areas of supervision required for each of the 8 surgical procedures. Determining themes was challenging because of the considerable diversity in terminology used. In addition, responses such as “everything,” “what's important,” and “the entire procedure” were problematic to categorize, as the intentions of the respondent were not clear. Thus, some responses may not have been adequately captured in the themes or tally. In defining themes, the authors endeavored to place them in a logical order on the basis of the procedure. Each set of themes was unique, although commonalities among procedures were identified (Tables 1–8).
Responses of 4 stakeholder groups (veterinary students [n = 1,731], recent graduates [ie, individuals who had graduated in the 2 previous years; 70], general practitioners [235], and faculty members [151] with a clinical focus) regarding specific areas of supervision required for new graduates performing, on their first day in practice, elective castration of a healthy 6-month-old dog. Some respondents listed ≥ 1 area of supervision.
| No. of respondents | ||||
|---|---|---|---|---|
| Area of supervision | Students | Recent graduates | General practitioners | Faculty members |
| Analgesia and anesthesia | 5 | 0 | 5 | 0 |
| Incision | 10 | 1 | 12 | 3 |
| Exteriorizing testicle | 6 | 0 | 6 | 4 |
| Ligature placement | 20 | 1 | 13 | 5 |
| Ensuring hemostasis | 21 | 1 | 19 | 6 |
| Closure | 17 | 2 | 18 | 4 |
| Complications | 45 | 3 | 9 | 6 |
| No. (%) who responded | 105 (6.1) | 7 (10) | 41 (17.4) | 25 (16.6) |
Responses of 4 stakeholder groups regarding specific areas of supervision required for new graduates performing, on their first day in practice, elective OVH in a healthy 6-month-old dog.
| No. of respondents | ||||
|---|---|---|---|---|
| Area of supervision | Students | Recent graduates | General practitioners | Faculty members |
| Analgesia and anesthesia | 6 | 0 | 1 | 0 |
| Incision | 16 | 2 | 22 | 8 |
| Abdominal exploration | 25 | 1 | 23 | 6 |
| Tissue handling and ligament breakdown | 18 | 2 | 27 | 8 |
| Ligature placement | 55 | 6 | 55 | 14 |
| Ensuring hemostasis | 61 | 4 | 40 | 12 |
| Closure | 33 | 4 | 33 | 9 |
| Complications | 62 | 4 | 11 | 5 |
| No. (%) who responded | 180 (10.4) | 11 (16) | 74 (31.5) | 25 (16.6) |
Responses of 4 stakeholder groups regarding specific areas of supervision required for new graduates performing, on their first day in practice, enucleation of the right eye because of glaucoma in an otherwise healthy 10-year-old dog.
| No. of respondnents | ||||
|---|---|---|---|---|
| Area of supervision | Students | Recent graduates | General practitioners | Faculty members |
| Analgesia and anesthesia | 177 | 2 | 35 | 3 |
| Surgical planning | 177 | 0 | 45 | 5 |
| Incision | 182 | 12 | 50 | 25 |
| Anatomic considerations | 283 | 16 | 59 | 19 |
| Tissue handling and dissection | 272 | 21 | 68 | 30 |
| Ligature placement | 211 | 15 | 57 | 22 |
| Ensuring hemostasis | 192 | 12 | 63 | 26 |
| Closure | 205 | 23 | 56 | 27 |
| Complications | 177 | 0 | 35 | 8 |
| No. (%) who responded | 426 (24.6) | 29 (41) | 126 (53.6) | 55 (36.4) |
Responses of 4 stakeholder groups regarding specific areas of supervision required for new graduates performing, on their first day in practice, a gastric foreign body removal in an otherwise healthy 12-month-old dog.
| No. of respondnents | ||||
|---|---|---|---|---|
| Area of supervision | Students | Recent graduates | General practitioners | Faculty members |
| Analgesia and anesthesia | 80 | 8 | 37 | 19 |
| Surgical planning | 119 | 16 | 65 | 26 |
| Incision | 106 | 11 | 50 | 20 |
| Abdominal exploration | 104 | 10 | 41 | 18 |
| Tissue handling | 94 | 11 | 41 | 18 |
| Hemostasis | 103 | 9 | 40 | 19 |
| Gastrotomy | 235 | 28 | 97 | 42 |
| Management of foreign body | 146 | 11 | 55 | 31 |
| Close gastric incision | 373 | 36 | 122 | 56 |
| Abdominal wall closure | 149 | 14 | 60 | 29 |
| Complications | 32 | 0 | 1 | 2 |
| No. (%) who responded | 506 (29.2) | 42 (60) | 141 (60.0) | 71 (47.0) |
Responses of 4 stakeholder groups regarding specific areas of supervision required for new graduates, on their first day in practice, removing a freely movable, benign, 4-cm-diameter subcutaneous mass from an otherwise healthy 9-year-old cat.
| No. of respondnents | ||||
|---|---|---|---|---|
| Area of supervision | Students | Recent graduates | General practitioners | Faculty members |
| Analgesia and anesthesia | 21 | 0 | 8 | 1 |
| Surgical planning | 27 | 0 | 16 | 12 |
| Incision | 40 | 5 | 21 | 11 |
| Dissection | 51 | 5 | 18 | 9 |
| Tissue handling | 29 | 2 | 10 | 5 |
| Hemostasis | 25 | 3 | 18 | 8 |
| Margins | 111 | 4 | 27 | 10 |
| Managing dead space | 14 | 1 | 9 | 2 |
| Closure | 75 | 7 | 41 | 13 |
| Complications | 31 | 3 | 14 | 2 |
| No. (%) who responded | 186 (10.7) | 15 (21) | 64 (27.2) | 31 (20.5) |
Responses of 4 stakeholder groups regarding specific areas of supervision required for new graduates, on their first day in practice, repairing a 2-hour-old, full-thickness, 2-cm-long upper eyelid laceration in a 6-year-old horse.
| No. of respondnents | ||||
|---|---|---|---|---|
| Area of supervision | Students | Recent graduates | General practitioners | Faculty members |
| Analgesia and anesthesia | 41 | 1 | 11 | 5 |
| Surgical planning | 49 | 1 | 7 | 7 |
| Tissue handling | 42 | 3 | 9 | 9 |
| Hemostasis | 36 | 1 | 9 | 5 |
| Tissue viability and debridement | 46 | 4 | 12 | 11 |
| Closure | 182 | 18 | 58 | 35 |
| Complications | 53 | 1 | 8 | 6 |
| No. (%) who responded | 273 (15.8) | 18 (26) | 76 (32.3) | 42 (27.8) |
Responses of 4 stakeholder groups regarding specific areas of supervision required for new graduates, on their first day in practice, repairing a 1-hour-old, 10 × 10-cm cutaneous wound that had resulted in a ventrally hanging triangular flap with smooth tissue margins over the pectoral muscles of a 1-year-old horse.
| No. of respondnents | ||||
|---|---|---|---|---|
| Area of supervision | Students | Recent graduates | General practitioners | Faculty members |
| Planning | 56 | 4 | 25 | 23 |
| Wound exploration | 55 | 2 | 28 | 9 |
| Wound preparation and debridement | 142 | 7 | 56 | 35 |
| Tissue handling | 48 | 3 | 27 | 8 |
| Managing dead space | 227 | 15 | 56 | 32 |
| Closure | 234 | 14 | 71 | 8 |
| Complications | 15 | 0 | 0 | 1 |
| No. (%) who responded | 310 (17.9) | 21 (30) | 104 (44.3) | 54 (35.8) |
Responses of 4 stakeholder groups regarding specific areas of supervision required for new graduates, on their first day in practice, performing an emergency cesarean section in a 5-year-old cow that had been in stage 2 labor for 3 hours.
| No. of respondnents | ||||
|---|---|---|---|---|
| Area of supervision | Students | Recent graduates | General practitioners | Faculty members |
| Analgesia and anesthesia | 155 | 7 | 61 | 18 |
| Surgical planning | 159 | 2 | 11 | 24 |
| Abdominal incision | 193 | 11 | 77 | 21 |
| Uterine incision | 225 | 14 | 76 | 21 |
| Hemostasis | 166 | 7 | 57 | 15 |
| Fetal extraction | 224 | 10 | 71 | 31 |
| Uterine closure | 253 | 15 | 82 | 40 |
| Body wall closure | 203 | 8 | 71 | 31 |
| Complications | 9 | 0 | 3 | 15 |
| No. (%) who responded | 393 (22.7) | 23 (33) | 117 (49.8) | 57 (37.7) |
Responses related to specific procedures usually included multiple steps, such as “proper sedation, proper ligation and incision locations, proper closure”; “location of skin incision, open versus closed castration, ensuring that both testicles were removed in their entirety”; and “proper tissue handling, making sure proper landmarks are identified.” Some responses were not related to the steps of the surgical procedure (eg, “none in particular but this is your first day and it is my practice. I want to be sure that all work is done to my standards”).
Responses to the open-text question on additional diagnostic and surgical procedures to which students should be exposed varied widely. Additional skills respondents listed that they thought new graduates should be proficient in on their first day of practice included ligation of vessels by various methods; atraumatic tissue handling; anesthesia principles, including analgesia and monitoring; making skin and viscera incisions; closing skin and viscera incisions with proper tissue apposition; application of surgical anatomy; correct aseptic technique with gowning, gloving, and intraoperative asepsis; wound management with drain placement and tension relief; appropriate suture material and pattern choice; and postoperative patient management. Additional skills and procedures respondents thought new graduates should have been exposed to included reproductive sterility procedures; orthopedics, including fracture stabilization, limb amputation, femoral head ostectomy, and dewclaw removal; dental procedures, including extractions; correct radiology positioning; gastrointestinal and intraabdominal surgery, including enterotomy, abomasopexy, gastropexy, splenectomy, and cystotomy; wound management with adequate bandaging and drain placement; perineal urethrostomy; and advanced anesthesia skills with endotracheal intubation and handling complications.
Discussion
The present study was intended to clarify expectations of various stakeholder groups (veterinary students, recent graduates, faculty members, and veterinary practitioners) regarding the ability of new graduates to perform, on their first day in practice, a variety of diagnostic and surgical procedures. The goals were to establish a guide for critical evaluation of veterinary college outcomes and to compare expectations among stakeholder groups. The data revealed a diversity of opinion regarding expected proficiency for the diagnostic and surgical procedures. In general, however, respondents had higher expectations for proficiency in performing common and relatively straightforward procedures such as aspiration of a subcutaneous mass, cystocentesis, and castration. Respondents generally expected new graduates to take more time to complete more complex procedures, and there was less agreement among stakeholder groups regarding expected proficiency when performing these more complex procedures. However, stakeholder groups had considerable overlap in regards to critical supervision points for the various surgical procedures.
In the present study, greater disagreement among stakeholder groups was apparent with procedures such as ultrasound-guided liver biopsy, arthrocentesis, and the various large animal surgical procedures. This finding was not surprising given the clinical focus of CVMs and the differences in how veterinarians see their role in veterinary practice. Recent graduates seemed to have lower expectations than the other stakeholder groups with respect to proficiency performing the various diagnostic procedures, but not with respect to performing the various surgical procedures. This was an interesting finding that warrants further investigation. One possibility is that CVMs may be placing a greater focus on performing surgery procedures, without a similar focus on diagnostic procedures. Unfortunately, no recent graduates currently enrolled in an internship program responded to the survey, and it may be of value to follow up with a focused evaluation of interns.
The present study was meant to be a starting point to develop more specific metrics related to outcomes, not an all-inclusive list of expectations of new graduates. The surgical procedures were chosen because they require a spectrum of foundational surgical skills (eg, suturing, working within body cavities, and controlling contamination) and represented a range of complexity. Importantly, the core skills required for many of these procedures differ little between species. Each surgical procedure was described with a specific clinical context (ie, elective castration of a healthy 6-month-old dog, rather than simply “canine castration”) in an attempt to more effectively communicate the complexity of each procedure.
Although respondents in the present study represented a broad cross section, they may not have necessarily been representative of the profession as a whole. Although nearly every CVM was represented by a student, faculty member, or practitioner, the number of respondents was not sufficient to allow comparisons between individual CVMs. Individual CVMs could have biases that play out in expectations of new graduates, and this may be worth further investigation. However, we did not identify significant differences among faculty members responding from different CVMs in the present study. Clearly, cultural and geographic differences in expectations exist. For instance, Bowlt et al19 found that in the United Kingdom, only 8% of respondents thought new graduates were competent to perform OVH unsupervised immediately after graduation, and 49% thought they were not competent to perform the procedure at all. In contrast, 65% to 89% of respondents in the present study thought that new graduates should be able to independently perform an OVH in a dog. Shifts in professional and societal norms may also result in changes in expectations over time. Castration, spay, and lumpectomy were listed in a 1997 study15 as being procedures a new graduate should be able to perform with little to no supervision, and most respondents in the present study indicated that they expected new graduates to be able to independently perform these procedures. Nevertheless, it is worth monitoring expectations to determine whether they are shifting over time.
Expected proficiency performing hand ties was included in the present study to allow comparisons with results of previous studies.5,6 Although we anticipated our results would be similar to those of previous studies,5,6 we actually found higher expected proficiency for hand ties than has been reported previously. For example, Hill et al6 reported that 36% and 61% of respondents, respectively, expected complete or good demonstration of 1-handed and 2-handed hand ties. By contrast, although we did not specify 1-handed versus 2-handed hand ties, 63% to 94% of respondents in the present study expected new graduates to be proficient. This may have represented a shift in the expectations for new graduates, perhaps because of changing academic dynamics or demands in practice, or may simply have been due to differences in question wording.
The low response rates in the present study, particularly for large animal faculty members and practitioners, increased the opportunity for systematic bias. Although the study was designed to reflect the mixed animal nature of the profession, many comments suggested that respondents in small animal practice were not comfortable offering their opinions on large animal procedures, despite the universality of the skills required to perform these procedures. Thus, the survey may need to be repeated with species-specific groups. For instance, only 24% to 63% of respondents thought that new graduates should be proficient performing an arthrocentesis. However, if only practitioners and faculty members in equine practices had been asked, the percentage likely would have been higher. Although species differences are important, the commonalities should not be ignored. That is, the foundational skills needed to repair a laceration in a horse or perform a cesarean section in a cow are arguably not substantially different from those required to remove a subcutaneous mass in a cat or perform an OVH in a dog. In our opinion, training programs should be focusing on the fundamental principles of surgery (eg, asepsis and indications for suture patterns), while still conveying important species differences.
Results of the present study related to specific areas of supervision required for each of the 8 surgical procedures should be interpreted with caution. Although it is useful to understand the expectations and concerns of the stakeholder groups, there were considerable weaknesses in the data. First, responses were obtained from only a small portion of survey participants, leaving a large potential for systematic bias between responders and nonresponders. Second, not all responses were easily coded, and themes may not have reflected the respondents' intent. Third, respondents did not necessarily list all the critical steps for each procedure. For instance, only 18% (33/180) of students and 36% (9/25) of faculty members indicated closure was a critical time for supervision of a new graduate performing an OVH in a dog, whereas one might argue that the most common complications seen when new graduates perform this procedure are hematomas and incisional infections. The supervision areas identified in the present study should be taken as a starting point, with further study and critical evaluation being warranted.
In the present study, we offered an open-text question for respondents to list additional diagnostic and surgical procedures to which they believe students should be exposed. Responses included many component surgical skills, such as hemostasis and closing skin and viscera incisions, along with specific surgical procedures, such as perineal urethrostomy, abomasopexy, and femoral head ostectomy. Dental procedures, anesthesia-related skills, and radiology positioning were additional areas that stakeholders listed. Respondents did not offer any recommendations for surgical procedures or component surgical skills that have not been included in previous studies.3–11 This was interesting considering the many changes, particularly technological changes, to the profession, such as the adoption of minimally invasive surgical techniques. Possibly, respondents did not believe that new graduates need to have these skills at the time of graduation. Diagnostic ultrasonography and endoscopy were mentioned by a few respondents as important skills, which may have represented training opportunities for CVMs.
In a recent study,31 24% of interns reported that their primary motivation for pursuing an internship was that they felt they needed more training. Providing students with clear objectives to achieve prior to graduation would allow them to optimize their time and efforts during their training and would encourage CVMs to make the most of teaching opportunities. Although decreasing caseloads and increasing student numbers are challenges for ensuring student readiness for graduation, ample evidence shows that alternative instructional strategies can achieve the same or better outcomes,25–28,32–39 and CVMs have pursued numerous strategies to meet student educational needs with limited resources.40–47
Clear and objective data for outcome assessment have been shown to be of value in human surgical training programs,26–28,34,36,38,48 but are lacking in veterinary medicine. Clearly defining expectations of new graduates and objectively measuring outcomes will allow for more meaningful veterinary training programs. Procedures can be broken down into their foundational skills, which can be taught individually before being put into context in the actual procedure. The benefit of having clear standards is that instruction can be directed in an efficient and effective manner.49,50 By starting with clear expectations and using a graduated approach, with outcomes (rather than time elapsed) determining advancement to the next stage of training, students can focus on mastering learning,26,27,49,50 and CVMs can capitalize on the transferability of skills learned in one procedure to another.
Clarifying expectations for supervision is important for both new graduates and employers, as results of the present study suggested that disparities exist between practitioners, recent graduates, and students regarding performance of new graduates. Expectations related to mentorship and supervision should be discussed during the hiring process.
The increasing complexity of practice and limited resources in academic veterinary medicine will increase the difficulty of adequately preparing new graduates for practice. Other health-care professions have worked to optimize training in the face of these constraints, but the classic apprenticeship model for training surgical skills may not be adequate to fulfill the needs of contemporary health care.32 Competency-based medical education is a relatively new concept, particularly in the veterinary field.51–53 One aspect of competency-based education is focusing on the context in which capabilities are demonstrated. This means, for example, recognizing the differences in expectations and needs between a veterinarian performing surgery in a state-of-the-art facility in a metropolitan area and a veterinarian performing the same procedure in a rural area without extensive resources.
Having clear guidelines for expected new graduate performance will enable CVMs to target assessments to key areas, such as those identified as requiring supervision, and focus on competence-based advancement rather than time in training.33,51 For instance, the discrete skills involved in castrating a dog could be learned and assessed before moving on to performing the procedure on a model and, subsequently, on a live animal. The timeline for advancement may be shorter for some students and longer for others depending on their motivation, natural abilities, and tendencies. Specialized outcome assessments such as objective structured clinical examinations can be used to determine specific cutoff points for evidence of effective skill development.
There are inherent challenges associated with survey research. The low response rate in the present study was an important limitation, particularly in regard to areas of required supervision. Low response rate to surveys is a widely reported problem, although some evidence suggests that surveys with low response rates can provide accurate results.54,55 To avoid context effects and subsequent question interpretation, questions were randomly presented to respondents. However, survey fatigue may have influenced the quality of responses, especially to open-text questions. An electronic survey was used for cost-effectiveness and ease of administration and data handling, but a limitation to electronic surveys is that a substantial percentage of the population does not have internet access.56 This may have partially accounted for the low number of responses obtained from large animal practitioners, in that many large animal practitioners are located in rural areas that may have limited or no internet access. The postcard containing an electronic link to the survey was also a cumbersome method that may have decreased the response rate, as it required entering the URL correctly to participate, rather than simply clicking on a link in an email message.
The North American Veterinary Medical Education Consortium has suggested that CVMs share resources,1 and recent efforts have been undertaken to share competency definitions.2 If we follow the lead of human health-care training organizations, we will likely find that a number of models can be used to understand expectations of new graduates in other areas.57–60 Of particular note is the Delphi process,61 which may be a valuable resource, as it allows stakeholders outside academic veterinary medicine to have an influence on the curriculum and outcome assessments. The Pediatrics Milestones Project of the American Board of Pediatrics provides an interesting model for the creation of a more complete set of expectations.57,60
Considerable work remains to be done in defining competency in veterinary practice, articulating expectations for new graduates, defining necessary areas of supervision, enhancing mentorship in practice, and providing targets that CVMs can use in developing their curricula. Each CVM has its own resources, culture, and mission that will potentially impact its expectations for new graduates. However, we hope the present study will be a catalyst for more clearly defining those expectations.
Acknowledgments
Financial support provided by the American Veterinary Medical Foundation and a Washington State University College of Veterinary Medicine Education Research Grant.
Preliminary data were presented at the International Veterinary Simulation in Teaching Conference, Calgary, AB, Canada, August 2012.
The authors thank Drs. Tomasina Lucia, Mike Hinckley, and Eryn Zeugschmidt for contributions to survey development and implementation and David Kennedy for advice on survey creation and incentives.
ABBREVIATIONS
| COE | Council on Education |
| CVM | College (or school) of veterinary medicine |
| FNA | Fine-needle aspirate |
| OVH | Ovariohysterectomy |
Footnotes
Research Core, Qualtrics, Provo, Utah.
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