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dissertation entitled

The Effect of An Interpersonal Process Recall (IPR)
Videotape and Operating Room Treatment Program on
Medical Student Learning, Emotional/Physiological Reactions,
and Attitudes in Early Surgical Training:

An Experimental Study
presented by

Russell E. Hogan

has been accepted towards fulfillment
of the requirements for

 

 

Ph. D. degreein Counseling, Personnel
Services and Educational
Psychology

   

Major profes

Date August 13, 1982

MS U is an Affirmative Action/Equal Opportunity Institution 0- 12771

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The Effect of An Interpersonal Process Recall (IPR) Video-
tape and Operating Room Treatment Program on Medical
Student Learning, Emotional/Physiological Reactions,

and Attitudes in Early Surgical Training:

An Experimental Study

BY

Russell Edward Hogan

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Counseling, Personnel Services and

Educational Psychology
1982

ABSTRACT
The Effect of An Interpersonal Process Recall (IPR) Video-
tape and Operating Room Treatment Program on Medical
Student Learning, Emotional/Physiological Reactions,
and Attitudes in Early Surgical Training:

An Experimental Study

BY

Russell Edward Hogan

The incidence of medical students' adverse reactions to
common surgical stimuli was documented by Coppola and
Cochran. One-third of these students (n= 106), surveyed
during their surgical clerkships, reported apprehension
about observing and assisting in surgical procedures. The
present study attempted to investigate the effect of a
treatment program on these adverse reactions and on medical
students' learning, attitudes, and career preference.

Forty-five first and second year students from the
Colleges of Human and Osteopathic Medicine at Michigan State
University participated in the study. A three-group
posttest-only control group design was used. Group One

received two Interpersonal Process Recall (IPR) laboratory

sessions. These students were then videotaped while
observing an operation, watched the videotape, and disCussed
their reactions. Group Two students observed one operation.
Group Three received no treatment. All students observed an
operation and completed eight instruments measuring
emotional-physiological reactivity, learning, attitudes
toward themselves and surgeons, career preference, and
impressions of the operating room experience.

Analysis of variance and chi-square analysis indicated
no significant differences among the groups. The results of
chi-square analysis of the career preference measure
approached significance, suggesting a more positive attitude
toward aurgery on the part of Group'One students. Sample
size, however, required cautious interpretation of this
result.

Medical student interest in surgical experiences early
in medical school was discussed. The collaboration of
psychology and medicine in this surgical education study was

emphasized.

Dedicated
to
my family,
especially my mother,
who gave to me and showed me
many ways of being

ACKNOWLEDGMENTS

I would like to acknowledge and thank those who

contributed to the successful completion of this project:

Dr. Norman Kagan, chairperson of my committee, who
provided a firm base for me throughout the course of my
program.

Dr. Ed Coppola, who sparked this investigation and
firmly believed that surgeons are human too.

Dr. Bruce Burke, who gave creative criticism in an
easy manner and was generous with his optimism.

Dr. Tessa Cochran, who documented the problem and
freely gave of her insight into medical education.

Dr. Rebecca Henry, who contributed her knowledge of
research and saw me through the last draft.

Dr. Dave Wenger, who has been a steadfast source of
support and encourgement to me through my program.

Mike Lieberman, who shared three years of ups and
downs with me in the lab, including this project.

Liz Leistikow, who was the technical supervisor and
was largely responsible for producing the vignettes and for
the smooth running of the hospital phase of the project.

Lew Dotterer, Jim Azar, and Jerry Hermanson, who

sensitively performed as inquirers in the project.

iii

The participating surgeons and the staff of the
surgical unit at Ingham Medical Center, especially Mrs. Barb
Bennington, who strive to make the operating room a place of
healing.

Gabbi Belli, who guided me, through the data analysis
in a relatively painless way.

Dawn Wyllie, who advised me on practical aspects of
the treatment and outcome measures.

Bob Matson, who frequently brought order from chaos in
his calm, gentle way.

Carol Piper, Karen Ammarman, Margaret Savory, and
Lynnette Benjamin, who performed considerable clerical work
in the project.

‘Wendy Fielder, who shared the last and most difficult
part of the journey with me and warmed my heart.

My friends Bill Parker, John Snyder, Frank Pasciuti,
Jim Millhouse, and Jim Fritz, whose understanding, support,
and presence sustained me.

The people of the Michigan State University Counseling
Center, especially the West Fee Branch, and of Baton County
Counseling Center, who opened doors for me and let me learn.

The medical students who participated, some of whom

will one day be surgeons.

TABLE OF CONTENTS

LIST OF TABLES O O O O O O O O O O O O O O O O 0

LI ST OF FIGURES O O O O O O O O O O O O O O O 0

CHAPTER

I

II

III

The PIOblem O O 0 O O O O O O O O O O O O 0

Introduction . . . . .
Incidence of the Problem
Need for the Study . . .
Theoretical Framework . .
Treatment . . . . . . .
Definition of Terms . . . . . . . . . . . .
Assumption . . . . . . . . . . . . . . . .
Research Questions . . . . . . . . . . . .

Review of Literature . . . . . . . . . . .

IntrOductj-on O O O O O O O O O O O O O O O

Emotion and Learning . . . . . .
The Clerkship in Medical Students' Career
ChOice O O O 0 O O O O O 0

Medical Students' Attitudes Toward Surgeons

and Surgery . . . . . . . . . . . . . . .
Interpersonal Process Recall (IPR) . . . .
The Embelton Study (1981) . . . . . . . . .

Methods and Procedures . . . . . . . . . .

Population
Sample . .
Design . . .
Treatment . . . . . . . . . . .
Assignment to Experimental Conditions
Two—Phase Laboratory Experience . . .
Introduction . . . . . . . . .
Physiological Wiring Procedure

Viewing of Vignettes . . . .
Recall . . . . . . . . . . . .
Instructional Component . . . .
Hospital Experience . . . . . . . .
Introduction . . . . . . . . .
Group One Recall of Observation
Operation . . . . . . . . .

000000000

Page
viii

‘ix

Group Two Observation of Operation . . . 67

O.R. Observation by Triplets. . . . . . . 69

Instrumentation . . . . . . . . . . . . . . . . 71

Introduction . . . . . . . . . . . . . . . . 71
Measures of Emotional-Physiological

Reactivity . . . . . . . . . . . . . . . 72

Learning (Observation) Measure . . . . . . . 75

Attitudinal Measures . . . . . . . . . . . 76
Medical Specialty Questionnaire . . . . . . . 81
Impression Paragraph . . . . . . . . . . . . 82
Interim Observation Form . . . . . . . . . . 82
Experimental Hypotheses . . . . . . . . . . . 83
Delimitations . . . . . . . . . . . . . . . . . 85

Results . . . . . . . . . . . . . . . . . . . . 86

Introduction . . . . . . . . . . . . . . . . . . 86
Emotional—Physiological Reactivity . . . . . . . 88
Hypotheses . . . . . . . . . . . . . . . . 88
Scoring of Measures . . . . . . . . . . . . 88
Results . . . . . . . . . . . . . . . . . . 89
Learning (Observation) . . . . . . . . . . . . . 90
Hypothesis . . . . . . . . . . . . . . . . . 90
Scoring of Measure . . . . . . . . . . . . . 90
Results . . . . . . . . . . . . . . . . . . 90
Attitudes . . . . . . . . . . . . . . . . . . . 90
Hypothesis . . . . . . . . . . . . . . . . . 90
Scoring of Measures . . . . . . . . . . . . 91
Results . . . . . . . . . . . . . . . . . . 91
Specialty Rankings . . . . . . . . . . . . . . . 92
Hypothesis . . . . . . . . . . . . . . . . . 92
Scoring of Measure . . . . . . . . . . . . . 92
Results . . . . . . . . . . . . . . . . . . . 92

o
o
o
o
o
c
o
o
o
o
\0
w

Impressions . . . . . . . .
Hypothesis . . . . . . . . . . . . . . . . . 93
Scoring of Measure . . . . . . . . . . . 93
Results . . . . . . . . . . . . . . . . . . . 94

Summary, Conclusions, Discussion and
Implications . . . . . . . . . . . . . . . . 100

Summary .. . .. . . .. .. .. .. .. .. 100
Conclusions . . . . . . . . . . . . . . . . . . . 105
Discussion . . . . . . . . . . . . . . . . . . . 107
Sample . . . . . . . . . . . . . . . . . . . 107
Theory . . . . . . . . . . . . . . . . . . . 109
Treatment . . . . . . . . . . . . . . . . . 112
Instrumentation . . . . . . . . . . . . . . 114
Implications . . . . . . . . . . . . . . . . . . 115

vi

APPENDICES

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

INVITATION TO PARTICIPATE
PARTICIPATION FORM . . .
INQUIRER PROCEDURES . .
TYPESCRIPTS OF VIGNETTES

TRANSCRIPT OF INSTRUCTIONAL C

LETTER TO SURGEONS . . .
INFORMED CONSENT FORM .
INSTRUCTION SHEET . . .
OUTCOME MEASURES . . . .
INTERIM OBSERVATION FORM

REFERENCES . . . . . . . . . . .

vii

O O O O O o. O O O

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118
120
121
122
124
125
126
127
128
141

142

Table
3.1.
4.1.
4.2.
4.3.

LIST OF TABLES

Participant Characteristics

Means and Standard Deviations

Summary of Analysis of Variance

Tests on Surgery Ranking .

viii

O

Page
52
95
97

99

LI ST OF FIGURES

Figure Page

1.1. Model Employed by Information Processing
Theories of Learning . . . . . . . . . . . . . . 13

3.1. DeSign Of StUdy I O O O O O O O O O O O O O O O O 54
3.2. Diagram of Experimental Procedures . . . . . . . 56

3.3. Floor Plan of IPR Laboratory Suite . . . . . . . 58

ix

CHAPTER I

THE PROBLEM

Introduction

 

Thisstudy was an investigation of the relationship
among physiological-emotional responses, learning, and atti-
tudes.of first and second year medical students just prior
to their surgical clerkships. The investigation was an
exploratory experimental study evaluating the effectiveness
of an Interpersonal Process Recall (IPR) (Kagan, 1975, 1979)
pre-surgical clerkship experience. The purpose of the
treatment was to increase learning and decrease the negative
impact of common operating room stimuli on medical students
in their early surgical training.

This chapter includes a discussion of the events lea-
ding to the explication of the incidence of the problem, the
need for the study, the theoretical framework in which the
problem was conceptualized, a brief description of the
treatment approach, definition of terms, assumptions
employed in the study, and a general statement of the

research questions.

Incidence Of The Problem

Through discussions with students before, during, and
after the students' participation in the surgical clerkship,
Coppola and Cochran (1979) noted that some students tended
to be frightened by or apprehensive about observing,
assisting in, or performing surgical procedures“ Coppola
and Cochran reasoned that, depending upon the actual
incidence of such reactions in medical students, these reac-
tions might have significant effects in two areas: 1) the
medical student's attention to the learning of necessary
information and skills involved in surgery and 2) the
student's viewpoint toward and possible consideration of
surgery as a career specialty.‘ Coppola and Cochran's
specific concerns were that students' apprehension about
surgery might detract from their learning in the operating
room, contribute to a.re1atively negative attitude toward
surgery and/or surgeons, and perhaps dissuade some students
from considering surgery as a career specialty. The latter
concerns related to issues of medical student self-percep-
tion and attitudes about surgery and surgeons, and the
influence of these factors on career selection. If some
students perceived themselves as overly reactive to common
surgical stimuli and judged that this over-reactivity was
unchangeable or maladaptive in terms of consideration of
surgery as a career specialty, then these students might
rule out surgery as a career option. Stated another way, if

some medical students held a stereotypical view of surgeons

3

as insensitive to surgical stimuli, and if these students
saw themselves as highly sensitive to these stimuli, they
might have viewed themselves as unsuitable for surgical
careers. The stereotype of the surgical personality for
some students may have been transformed into a self-
fulfilling prophecy. "The underlying assumption . .. is
that surgical professional competency requires traits and
characteristics in the surgeon which are incompatible with
the needs of patients for sensitivity, compassion, and
understanding during an experience of great personal pain
and danger" (Coppola 8 Cochran, 1979). If this was in fact
occurring, then

surgery may be losing a group of bright, sensitive

and thoughtful recruits who might otherwise be

interested in surgical careers if they could be

trained to cope successfully with their reactions

to noxious surgical stimuli (Coppola, 1980).

In.order to first investigate the actual incidence of
this phenomenon, Coppola and Cochran devised the Apprehen-
sion to Surgical Procedures Questionnaire (ASPQ) which was
administered in March and June, 1979, to Michigan State
University College of Human Medicine students at the end of
the ninth week of their twelve-week surgical clerkships.
These were third and fourth year students, a11«of whom had
completed a minimum of two years of pre-clinical coursework.
The questionnaire asked several short-answer questions about
the presence, nature, extent, intensity, duration and change

of such adverse reactions to surgical stimuli. The results

4
from this first questionnaire confirmed Coppola and
Cochran's earlier observations. Of 72 medical students
surveyed on their surgical clerkships, one—third indicated
they had experienced physiological reactions such as feeling
faint or nauseated while they were in the operating room.
Students were asked to describe the reactions they had
experienced, to determine if these reactions were related to
specific types of operations or operating room stimuli, and
to describe what they had done to cope with these reactions.
They were also asked to check the extent to which each of 42
specific stimuli bothered.thenu The data indicated there
were emotional as well as physiological components to these
reactions and that the reactions frequently seemed tied to
specific (”excision of nails of great toes") or general

1 is used") opera-

("1ong operations; operations where Bovie
ting room stimuli. Interpersonal stimuli (e4L "surgeon's
expression of anger," "surgeon making disparaging remarks",
distinct from actual surgical or anatomical stimuli (e4p
”intubation," "incision," "blood"), also were identified by
students as contributing to their adverse reactions in the
operating room.

The confirmation of the existence of adverse

physiological/emotional reactions to both "surgical” and

”interpersonal” operating room stimuli on the part of

 

1Bovie: electro-cautery unit

5
approximately one-third of the medical students surveyed led
Coppola and Cochran to consider more seriously the implica-
tions of this phenomenon. Did these adverse reactions
interfere in some way with the students' learning process
while in the operating room? Did these reactions perhaps
affect the medical studentfs attitudes about self or toward
surgeons and surgery in such a way that the student might:
1) have a relatively negative attitude toward surgeons or
surgery, or 2) decide against surgery as a career specialty?

The incidence and intensity of medical students' reac—
tions to surgical stimuli as reported on this questionnaire
seemed to be inversely related to surgery-related experi-
ence, that is, the more experience the less reported reac-
tion, but neither the level of the reactions nor the process
by which the reactions decreased was clear. For example, if
the student's initial adverse reaction to surgical stimuli
was 20 on a scale measuring the intensity or duration of the
reaction, it was not clear if the reaction decreased to 10
or 5. Since this was unclear, the relative effect that a
preparatory treatment experience might have on the level of
these reactions was also unclear.

With these issues in mind, Coppola and Cochran began
considering strategies for further verifying the incidence
of the problem as well as for investigating the possible
relationship>between these reactions and the learning and
attitudes of medical students on their surgical clerkships.

Though still in an exploratory stage, these ideas seemed

6

sufficiently well defined to be subjected to experimental
study. Realizing that these reactions to various operating
room stimuli were the dependent variables in this situation,
Coppola and Cochran began considering means of ameliorating
the impact of these stimuli on medical students and thereby
perhaps increasing their learnimg and improving their
attitudes toward surgeons and surgery. A training
experience was sought which would be pertinent to:

l) The identified stimuli, both surgical and

interpersonal

2) 'The physiological/emotional components of the

medical student's reactions to these stimuli.
In addition, Coppola and Cochran sought a training
experience which would be positive, both in process and
outcome, for the medical students by fostering increased
awareness, acceptance, and perception.of control of their
reactions and of themselves.

Aware of the research of Kagan to increase the
interpersonal effectiveness of medical students in patient
interviews through the use of the Interpersonal Process
Recall (IPR) method (Kagan, 1975, 1979), Coppola and Cochran
(1979) concluded that this method might influence students'
adverse reactions to surgical stimuli and students'
learning in their surgery clerkships. Embelton's study,
conducted in 1979, grew out of the collaboration of
Embelton, Kagan, Coppola, and Cochran in the initial

exploration of this possibility. Embelton used a matched-

7
pairs design to test the effectiveness of a treatment
consisting of two laboratory I.P.R. sessions (viewing
videotaped "vignettes" of actual and simulated surgical
situations) on early surgical learnimg and anxiety in
medical students. Embeltonfis study is reviewed in Chapter
2. The IPR method employed in Embeltonls study and in this
study is discussed specifically in this chapter and in
Chapter 2, and the general rationale for the choice of this
treatment approach is presented in Chapter One. The present
study grew directly from the Embelton study and was an
attempt to:

1) Strengthen the Embelton treatment by adding an
instructional videotape and an actual operating
room IPR session.

2) Improve the design by using three groups instead
of two and by using experience as a blocking
variable.

2” Improve and expand the scope of the outcome
measures by improving their objectivity and
validity.

4) Incorporate an exploration of medical student
attitudes toward themselves and surgery.

The remaining sections of this chapter address the need
for the study, the theoretical framework used in the present
study, a discussion of the treatment approach, definition of
terms, assumptions, and a statement of the research ques-

tions.

Need For The Study

Although Embelton found no significant differences
between experimental and control groups on either learning
or anxiety, this lack of significant differences could have
resulted from weaknesses in the treatment, design, and/or
outcome measures (Embelton, 1981). The present study
addressed these weaknesses in a more rigorous attempt to
discover any differences which might exist but were not
found by Embelton. Specific modifications and additions
made in this study are presented in Chapter Two.

The need for the present study was further indicated by
the results of the administration of the 1980 ASPQ question-
naire to sixty-eight medical students on their surgical
clerkships. These results confirmed the earlier finding
that nearly one-third (29%)iof theSe students experienced
some unpleasant reaction to operating room stimuli. The
present investigation was significant for two reasons.
First, the investigation attempted to determine if a
relationship existed between students' reactions and subse-
quent learning (observation) in the operating room. The
importance of such a relationship becomes clear when one
considers the ubiquity of the surgical clerkship in American
medical education. Of the 130 North American allopathic

medical schools indexed ix: the 1978-79 Association of

 

.American Medical Colleges Curriculum Directogy, 120 included
a required surgical clerkship of between four and sixteen

weeks. These clerkships include general surgery clerkships

9

as well.as clerkships in various surgical specialties. If
adverse emotional/physiological reactions to surgical
stimuli were present in about one-third of all medical
students entering their surgical clerkships and if these
reactions were found to significantly interfere with
observation in the operating room, important issues would be
raised for surgical education. The meaningful significance
of the results, as well as other specific data to be
gathered in the study, could be a guide for further research
as well as foster consideration of a heretofore largely
ignored phenomenon in surgical education.

Secondly, a study was needed to determine if a
relationship existed among these adverse reactions to
surgical stimuli and medical students' attitudes toward
themselves and toward surgery as a career specialty.
Embelton (1981) confined his study to the investigation of
the adverse reactions/learning relationship. In addition to
exploring this relationship more rigorously, the present
study sought to investigate this adverse reactions/attitudes
relationship. Previous reports (Burke, 1979; Linn, Pratt, &
Zeppa, 1979; Chapman, 1976) have indicated the importance of
clerkships in the career decisions of medical students,
especially the approximately one-third of students who have
not made fairly firm career decisions by their senior year
(Chapman, 1976). But there has been little actual research
on the influence»of clerkships on career choice. If there

is a link between the medical studentls experience on the

 

10
surgical clerkship and later career choice, then the
possible influence of adverse reactions to surgical stimuli
on the student's surgical clerkship experience becomes an
important issue. This issue is perhaps most clearly focused
in the medical student who is one of the one-third who seem
to‘experience adverse reactions as well as one of the one-
third who are unsure of their career choices. The present
study, though it did not undertake a longitudinal analysis
of actual career choices of the participating students, did
attempt to explore student attitudes toward surgery and
other specialties and the possible relationship of these to
adverse reactions to surgery. In addition, apart from
concerns regarding the effects of adverse reactions on
learning and attitudes toward surgery, the present study
also addressed the relationship between these reactions and
medical students attitudes toward themselves in general and
specifically toward themselves in the operating room. The
need for investigation of this question related to the issue
of the possible relationship between medical student self-
perception regarding these adverse reactions and the
stereotype of the surgeon as a cold, insensitive mechanic.
The following section outlines the theoretical framework in
which the adverse reactions/learning (observation) relation-

ship was conceptualized in the present study.

11

Theoretical Framework

An investigation of the early surgical learning of
medical students requires some conceptualization of the
phenomenon of learning. Of the three major schools of
psychological thought, psychoanalytic and its derivatives,
behavioral, and existential/phenomenological, the behavioral
school has concentrated most on investigating the specific
processes and events by which learning occurs. From its
origins of classical and operant conditioning, in which the
organism was thought to respond quite simply and directly to
external stimuli and in which response strength was
determined by reinforcement, mainstream behaviorism
gradually moved to a position of recognition of "intervening
variables” CTolman, 1938) in its basic stimulus-response-
reinforcement paradigm. This position marked acceptance of
the organism's mediation of its response through the
occurrence of internal processes and events, the
"intervening variables." Central among these variables were
sensation, perception, memory, and thinking. The acceptance
of variables present in the learning process other than
those which are observable pointed toward the possibility of
common ground with psychodynamic approaches, which
emphasized intrapsychic structures and processes, and with
existential approaches to the person, which emphasize the
individual's unique experience. From this point, investiga-
tion into the nature of these intervening variables, the

hypothesized internal structures and processes by which

12
learning occurs, moved toward research and theorizing which
focused primarily on building conceptual models to represent
the learning process and on testing these models experimen-
tally. Animal learning and verbal learning studies concen-
trated primarily on the investigation of relatively simple
processes of association. In contrast, a new line of
research extended in recent years to the study of more
complex mental structures and processes, e4L, perception
and memory. The field of cognitive psychology, drawing on
information theory, computer science, and linguistics, has
gradually emerged as an integrative effort espousing gener-
ally the following set of beliefs regarding the way by which
the mind processes information:

1. The importance of the selection of stimulus
information. Most of the time more information
impinges on us than our limited capacities can
handle.

2. The importance of selecting appropriate processing
strategies (largely under voluntary control) to
meet the demands of the task.

3. The development of cognitive structures. After
repeated applications of processing procedures,
stable cognitive structures emerge.

4. The interrelated functions of the parts of the
human mind as a coherent system.

5. The constantly active nature of cognitive

processes. The system is always active and at

13
work. (Reynolds & Flagg, 1977: p. 12)

Inherent in the cognitive psychology view of learning is a
reliance on models to approximate and attempt to explain the
processes of learning. These information-processing models
posit internal mental structures and the kinds of processing
which these structures accomplish. One such model drawing
on several others, was proposed by Gagne' (1977). This
model, as well as a discussion of the specific structures
and processes it contains, is presented below. Although
learning can be explained in psychodynamic and, perhaps less
clearly so, in existential terms, the information processing
model is the theoretical model of learning employed in this
study. The model has the advantages of relative precision,
parsimony and operationalism and does hold promise for
learning research, but a significant weakness of the model,
and of cognitive psychology in general, is discussed
following the presentation of the model.

Figure 1.1: Model Employed by Information Processing
Theories of Learning.

 

 

 

 

Executive Control Expectancie4

¢&& $1.1,

 

 

 

 

 

 

 

€__Effectors 6... Response
Generator *

 

 

 

 

 

 

 

 

 

 

; Receptors‘ ; Sensory \ Short-term‘——9' Long-term
Register Memory <%- Memory

 

 

 

 

 

 

 

 

 

 

BZMZZONH<ZM

 

 

 

 

 

(Gagne', 1977, p. 53; Anderson & Bower, 1973; Atkinson &
Shiffrin, 1968; Rumelhart, Lindsay, & Norman, 1972).

14

The receptors of the learner are activated by
environmental stimulation and this information persists very
briefly in the sensory register. Selective perception of
this sensory representation occurs as the learner attends to
certain features of the contents of the sensory register
while ignoring others. The sensory elements to which the
learner attends, synthesized by the process of selective
perception, enter short-term memory, where they persist for
a limited time, up to about twenty seconds. Short—term
memory seems to have a limited capacity, generally thought
to be about "seven plus or minus two" (Miller, 1956)
individual items. When this capacity is exceeded, old items
are pushed out as new items are added.

The process of encoding, by which short-term memory
information enters long-term memory, is crucial for
learning. Certain perceptual features in short-term memory
are transformed into a conceptual mode which is semantic, or
meaningfully organized. Material may be encoded as proposi-
tions, hierarchical or topical relationships of concepts,
and visual and other kinds of imagery. The encoded informa-
tion is stored in long-term memory. Some evidence suggests
that storage here is permanent and does not suffer loss
through time (Adams, 1967), but what is stored may become
inaccessible for a number of reasons. Interference between
new and older memories may block accessibility, and
forgetting may be due to the ineffectiveness of search and

retrieval processes. Retrieval of long— term memory

15

information seems to require that external or internal cues
(stimuli) be provided. These cues are employed in the
search process to recognize and retrieve long-term memory
material. This material may then re-enter short-term
memory, which may function as a working or conscious memory
(Atkinson & Shiffrin, 1968), where it becomes accessible for
new encoding transformations;cn:it may directly activate
the response generator, which organizes the form and pattern
of the upcoming performance. Activation of effectors
results in performance, the externally observable evidence
of learning. Reinforcement occurs as a result of feedback,
the learner's observation and interpretation of the effects
of his/her performance.

Executive control processes and expectancies, largely
acquired by the individual in previous learning and there-
fore constituting another portion or aspect of long-term
‘memory, determine the learner's approach to one or more ways
of processing information. Executive control processes and
expectancies are capable of affecting any and all of the
phases of information processing. The cognitive strategies
employed by learners to regulate their own internal
processes of attending, learning, remembering and thinking
are examples of executive control processes. These
processes can exert pervasive influence on the various
structures and events of the learning process. .The
learner's expectancies, what s/he intends and expects to

accomplish, can also influence all aspects of information

l6

processing. This concept is related to the purposive aspect
of Tolmands (1932) molar behavior and t1) the efficacy
expectations of Bandura (1971). It is important to note
that executive control processes and expectancies are
themselves learned, shaped by the individual's prior
experience and influencing the manner in which the learner
functions in the present. Also, external events quite
obviously influence the learning process, either by promo-
ting or inhibiting it.

.A weakness of the information-processing model and of
cognitive psychology in general is the relative lack of
recognition of the importance of emotion in the learning
process. Indeed, the word "emotion" is not even listed in
the table of contents of current texts in this area
(Reynolds & Flagg, 1977; Gagne, 1977). These theorists
would presumably subsume the emotional context of the
learning situation under the aspects of executive control,
expectancies and external events, with no more specific
attention to the impact of feelings on the individual's
processing of information. Cognitive psychology and
information-processing theories exhibit a possibly partly
reactive philosophical and practical emphasis on conscious
thought while largely ignoring the rich contributions of
psychodynamic and existentialist theory to the understanding
of the influence of emotion on learning and behavior. A
growing body of research, however, is exploring the complex

relationship between emotional factors and the various

l7
aspects of the learning process. Chapter Two contains a
review of relevant literature on this relationship.

A consideration of the possible influence of emotional
factors in the context of an information-processing theory
of learning should expand our understanding of the specific
case under study here, that of the medical student in
early surgical training. These emotional factors might best
be viewed as a combination of the studentfis emotional style
and emotional-physiological reactions, partly determined by
this style, to the surgical scene. From the beginning to
the end of the learning process, there are several points at
which emotional factors, sometimes manifested physiologi-
cally, might influence the outcome of the surgery-learning
process. Consider, for example, the medical studentds early
experiences of observing in the operating room. The student
dons surgical clothes and a mask and, amid the bustle of the
surgical suite -- patients, surgeons, nurses, technicians,
orderlies —- enters the O;R. The student takes in the
sights, sounds, smells and atmosphere of the OJL, including
the people, their attitude and behavior, the equipment and
instruments. Perhaps the student does not plan to be a
surgeon but is very interested in this event as an early
exposure to surgery. How does this affect him/her? What
reaction occurs when the patient is reminiscent of a
significant person in the student's life? Perhaps the opera-
tion itself has a significant emotional connotation for the

student. The patient is "prepped" as the surgeon enters the

18
room, and the medical student's expectation of "surgeon"
meets the reality of this specific experience of a surgeon.
As the O.R. personnel ready themselves and the O.R. for the
operation to begin, the tension mounts for the student.
(Embeltonfls 1981 study indicated that the medical students
generally felt more tension as the moment of the incision
approached.). Following the incision, the medical student
is witness to the complex interaction of the physical
progress of the operation itself with the surgeon and O.R.
staff. The scene includes the elemental stimuli of the
surgical procedure -- the cutting, clamping, stitching, etc.
of the live anatomy of the patient -- as well as the
relatively charged interpersonal interactions of patient
(conscious or unconscious), surgeon, anesthesiologist and
other O.R. personnel. There are several questions to be
asked. How is the reaction of the medical student to this
scene related to the quality of his/her observation during
the operation? Is there a relationship between the
student's reaction and attitudes toward surgery? Would
students who were less adversely affected by these stimuli
observe better than their peers? Can a training experience
prepare students to cope effectively with the emotional and
physiological components of their reactions to surgical

stimuli and improve their observation?

19

The Treatment

Traditionally, systematic desensitization procedures as
developed by Wolpe (1961) have been used to reduce anxiety
reactions of people threatened by specific stimuli. Such
procedures involve training in deep muscle relaxation and
construction of an anxiety hierarchy (a list of stimulus
situations which successively approximate the strongest
anxiety-evoking situationL. Individual training (usually
via imagery, sometimes ig gigg) is done in active substitu-
tion of the relaxation response for the anxiety response,
with the ultimate goal of relaxation in the highest anxiety
stimulus situation on the anxiety hierarchy. To the degree
that the documented unpleasant reactions of some medical
students to surgical stimuli may be termed “anxiety,” desen-
sitization was a possible choice for a treatment or training
experience to decrease the number and intensity of these
reactions. But systematic desensitization was deemed
inappropriate in the present study for both practical and
theoretical reasons. Individual systematic desensitization
usually requires from ten to twenty-five sessions (Wolpe,
1958). This requirement was prohibitive on a practical
basis. Although there is impressive evidence supporting the
effectiveness of the desensitization technique, Embelton
(1981) raises interesting theoretical issues about the
process by which a student's reactions to surgical stimuli
might change as well as about the implications of this

process and its outcome for awareness and future learning.

20
He states:

there is a strong element of the therapist or
experimenter being in control of the learning
and the patient or subject being the recipient
of the technique. There is yet another factor
that relates more specifically to this study.
Is it preferable to have medical students
”desensitized" to surgical stimuli or should
they be "sensitized" to the whole surgical
experience? The term sensitized is used here
in the sense of the ability to express both
cognitively and emotionally the impact of the
procedure upon oneself without denying the
anxiety or threat that might be occurring . ..
Desensitization of anxiety inhibits the
awareness of stimuli whereas a process of
sensitization encourages the individual to
acknowledge and deal with the anxiety'of the
impact of stimuli and events. It would seem
that the latter process would be more helpful
in developing within students an awareness of
their own interpersonal and physiological
reactions. (Embelton, 1981, p.13) .

Sensitization or increasing the awareness of medical
students to their reactions to the surgical scene would
encompass Coppola and Cochranfs training criteria, outlined
above. On a philosophical level, a process of sensitization
indicates an acceptance of the reactions under study as
natural responses to surgical stimuli. Sensitization thus
represents both a means and an end, a process and an
outcome, different from that represented by desensitization.
Sensitization represents an accepting recognition of the
naturalness of the reactions under study, a recognition
which implies that increased awareness and understanding of
these reactions will foster self— and other-awareness
resulting in a more sensitive and rewarding approach to

patient care.

21

Other treatment approaches and training programs such
as Anxiety Management Training (Suinn, 1977) seemed to
embody techniques and principles similar to those of
systematic desensitization and were ruled out of the present
study for similar practical and theoretical-philosophical
reasons. In addition, since the present study was developed
as a follow-up to the Embelton (1981) study, it was
desirable to build on a treatment already tested.

As in Embeltonfls study, the treatment approach employed
in the present study was the Interpersonal Process Recall
(IPR) method developed by Kagan (1979). The method
essentially involved the presentation of videotaped
"stimulus vignettes" which portrayed an actor or group of
actors simulating a "stimulus situation” which might have
emotional impact on the subject viewing the vignettes.
After viewing the vignettes, the subject discussed his/her
reactions with the help of an inquirer trained in the recall
process. The recall process was the core of the IPR method.
It enabled the subject to explore his/her reactions to
simulated, potentially powerful interpersonal situations in
a relatively non-threatening, person-centered context. The
inquirer's role was to facilitate the subject's exploration
of personal reactions to the vignettes by asking considered,
exploratory questions about the person's physical,
emotional, and cognitive experience while viewing the
vignettes. The IPR method has been used to improve inter-

actional skills in a variety of educational, mental health

22
and military settings. However, its use in the teaching of
patient interviewing skills to medical students (Werner &
Schneider, 1974) led Coppola, Cochran and Embelton to employ
the method as the treatment of choice in their investigation
of medical students' early reactions to surgical situations.
Their goal was to increase students' awareness and
acceptance of their reactions and thereby to improve early
learning in surgery. The IPR method and its specific use in
the present study are more fully explained in chapters Two

and Three.

Definition Of Terms

 

Emotional/Physiological Reactivity

The term "emotion" is used in this study to refer to
"complex, qualitatively different feeling-states or
conditions of the human organism that have both phenomen-
ological and physiological properties" (Spielberger, 1972,
EL27). Stimulus-response operations alone cannot account for
the breadth and depth of human emotional experience.
Individual personality and experiential differences must be
taken into account, for these crucial factors influence the
individual's appraisal of a particular situation and there-

fore his/her response to it (Lazarus and Opton, 1966).

Interpersonal Process Recall (IPR)
Interpersonal Process Recall is a method for
influencing human interaction developed by Kagan (1975,

1979). The essential element of the method is the "recall“,

23
or review, by audio or video tape,of an interaction by one
or more of the participants. This recall is facilitated by
an "inquirer" whose role is one of other-centered
exploratory questioning of the person with the goal of
maximizing the personfls awareness of emotional/cognitive
/physiological reactions during the taped interaction. The
inquirer respects the primary control of the person in
determining the scope and content of the recall. The
overall goal of the method is theienhancement of interac-
tions through increased awareness of oneH3”interpersonal
processesd” In further development of the model, videotaped
"stimulus vignettes" are used to simulate potentially
stressful interactions. Student subjects are filmed while
viewing these vignettes in a laboratory setting while
heartrate, skin conductance, and respiration are recorded by
a Grass recorder. In recent work, these physiological
measures are sampled by a computer and displayed in various
forms on a monitor during the recall. In the present study,
students viewed vignettes of actual and simulated surgical
scenes in the laboratory and also experienced a recall of an
actual operating room experience during which they were

videotaped.

Learning
In this study, a specific aspect of the learning
process, observation, was measured by the Operating Room

Experience inventory. Building on anatomy and physiology,

24
the learning of surgical procedures depended on observation
and gradual participation in the operating room through the
course of the surgical clerkship and possibly later the
internship and residency. According to Bandura (1971), a
great deal of human learning is accomplished vicariously,
through observation and subsequent imitation. This is

certainly true of the learning of surgical procedures.

Surgical Clerkship

The surgical clerkship is one of several "apprentice-
ships” which medical students serve following their initial
two to three years of preclinical coursework. Other
required clerkships are internal medicine, obstetrics-
gynecology, pediatrics, family practice, and psychiatry.
Surgery clerkships vary from four to sixteen weeks. The
College of Human Medicine at M.S.U. requires a twelve-week
general surgery clerkship. Elective four—week clerkships in
specialty fields (e.g. ophthalmology, urology) and a further
general surgery clerkship are available in addition to the
twelve-week requirement. The College of Osteopathic
Medicine at M.SJL has no surgery clerkship requirement.
During the clerkship, the medical student works full-time in
a hospital and spends about ten to fifteen hours per week in
the operating room. Student experiences vary of course with
the nature of the practice of the doctors to whom they are
assigned. The surgical clerkship is the primary period of

direct exposure to and practice in surgery for most medical

25
students who do not choose a surgery career, and it is
frequently the earliest intense experience in surgery for

future surgeons.

Assumption

 

The main assumption was that the physiological-
emotional reactions of M.SJL. medical students entering
their surgical clerkships are similar in kind and intensity

to those of other medical students.

Research Questions

This chapter attempted to document the pervasiveness of
medical students' adverse reactions in the O.R. (Cochran &
Coppola, 1982). The IPR method was described as one means
of reducing these reactions and ultimately improving early
surgical learning. The research questions which this study
addressed relate to: the nature of medical students'
emotional-physiological reactions to early surgical
experiences; the effects of these reactions on students'
observational ability in the operating room; the effects on
student attitudes toward themselves, surgeons, and surgery;
and the effects of an IPR -based treatment experience on
these variables. The specific hypotheses relating to these

general questions are stated in Chapter Three.

CHAPTER II

REVIEW OF LITERATURE

Introduction

This chapter contains a review of the literature on the
relationship between emotion and learning; the role of the
clerkship in medical students' career choice; medical
students' attitudes toward surgery and surgeons; and the
Interpersonal Process Recall method, especially as it
relates to medical student training. The last section of

the chapter reviews Embelton's 1979 study.

Emotion and Learning

The influence of emotional factors on learning has been
studied in a variety of ways. Investigation of the negative
impact of emotion on learning has been focused largely on
the relationship between anxiety and learning. This section
includes a review of theory and research on anxiety and
recent research on the relationship between emotion and
performance.

May (1977) surveyed the problem of anxiety in
literature, art, politics, philosophy, theology and
psychology. He characterized anxiety as both a perceived

threat and a positive challenge to life, to selfhood,

26

27
concluding that "the positive aspects of selfhood develop as
the individual confronts, moves through, and overcomes
anxiety-creating experiences" (May, 1977, pu356). Rogers
(1951) describes the relationship between threat and the
assimilation of experience (learning) thus:

The structure and organization of self appears to

become more right under threat; to relax its

boundaries when completely free from threat.

Experience which is perceived as inconsistent

with the self can only be assimilated if the

current organization of self is relaxed and

expanded to include it (p. 390).

Existentialists such as Kierkegaard (1944) have pointed out
that anxiety is a fact of life and that the creative
struggle with the anxiety associated with new possibilities
is the essence of hope for life. They also "insisted that
reality can be approached and experienced only by the whole
individual as a feeling and acting as well as a thinking
organism'I (May, 1977 p. 31).

Some theories of anxiety emphasized unsolved conflicts
within the self or between structural elements of the
personality. In his theory of personality, Freud (1924,
1933) first conceptualized anxiety as the result of
repression, reasoning that the affective components of id
impulses were transformed into anxiety when these impulses
were repressed. He later saw anxiety production as a
function of the ego when it perceived danger to itself,
whether the threat was internal (id impulse or superego

censure) or external. The ego took steps to reduce the

anxiety, steps such as repression and symptom formation.

28

The economic aspect of Freud's theory held that repression
was not a finished act when it occurred, but rather that a
constant expenditure of energy was required to maintain the
repression. Freud distinguished three kinds of anxiety: 1)
objective or realistic, implying a real known external
danger; 2) neurotic, implying an instinctual danger, a fear
of being overpowered by some impulse or thought that will
prove harmful; and 3) moral, implying a perception of danger
from the superego, experienced as feelings of guilt and
shame.

Following the progression of psychodynamic thought from
its early emphasis on instinctual influences, ego
psychologists later conceptualized anxiety in object
relations terms and in terms of a developmental progression.
They conceptualized early anxiety as a fear of annihilation
and later anxiety as fear of loss of a significant object or
of the objectls love. The prototypical anxiety experience,
upon which later anxiety is based, was that of separation
from the mothering person (Blanck & Blanck, 1974). The
severity of later anxiety experiences is related to the
extent to which adequate separation-individuation occurs in
this early developmental process.

The relationship between learning and anxiety in
psychoanalytic and ego psychological theory can best stated
in terms of the reality principle, by which the ego operates
in balancing the internal demands of the id and superego

with the requirements of the environment. Adaptive or

29

learned behavior, instrumental in adjusting the person to
reality, is done in the service of the reality principle.
The nature and degree of anxiety in the person directly
influence the defensive functions undertaken by the ego to
ward off the anxiety. With anxiety reduction as their goal,
these defensive functions require a distortion of reality in
proportion to the strength of the anxiety. Both the
defensive style employed by the individual (Shapiro, 1965)
and the degree of rigidity of this style exert primary
importance in the context of the learning situation.

While psychodynamic theory emphasized the character-
istic patterns of perception and behavior which a person
brings to a new situation, early behaviorists focused on the
properties of the stimulus situation and viewed the personus
response as being largely determined by the stimulus. In
terms of learning and anxiety, a response which serves to
reduce anxiety is reinforced by virtue of that fact. In an
attempt to integrate psychodynamic theory and reinforcement
learning theory, Dollard and Miller (1950) conceptualized
anxiety or fear as a major learned or secondary drive which
acquired its strength through association with primary
drives such as pain, thirst and hunger. Their principles of
learning are based on drive reduction as well the importance
of previous learning and the varied motivations of the
individual.

Miller and Dollard (1941) also contributed to the

emergence of social learning theory, which was articulated

30
more recently and thoroughly by Bandura (1969, 1971).
Bandura offered a synthesis of cognitive psychology's
emphasis on such processes as perception and memory and the
behavior modification focus on properties of the stimulus
situation such as reinforcement. While it accepts the
traditional learning theory emphasis on learning by doing
and the application of reinforcement contingencies to
practiced responses, social learning theory also holds that
a great deal of human learning is accomplished vicariously,
through observation and subsequent imitation. The observer
often learns and later performs novel responses without ever
having made them before and therefore without reinforcement.
A further contribution of social learning theory concerns
the important distinction between learning and performance.
In a study by Bandura, Grusec and Menlove (1966), children
observed a child model in a film perform a series of novel,
aggressive acts. The model received either rewarding,
neutral or punishing consequences in the film from a
”teacher.” ‘When the child was later allowed to perform in a
similar situation, the frequency of aggressive responses
imitating those of the model varied directly with the
reinforcement of the model shown in the film. However, when
incentives were offered in a second test for reproduction of
the model's behaviors, the differences in imitation virtu-
ally disappeared among subjects exposed to<differentially
rewarded models. 'The children had apparently learned the

same amount from observing the model's behavior but they

31

performed more or less of that behavior depending on whether
they "expected" to be reinforced for it. Furthering
Tolman's expectancy theory (summarized and interpreted by
MacCorquodale & Meehl, 1953, 1954), Bandura (1977) drew a
distinction between "outcome expectations,“ the belief that
a given behavior will lead to particular outcomes, and
"efficacy expectations," the belief that "one can success-
fully execute the behavior required to produce the outcomes“
(p. 193). Bandura subsumed ”anxiety,” a more psychodynamic-
existential term, under his efficacy expectations. 'These
are determined largely'byjperformance feedback from prior
experience and are the primary determinants, in Bandura's
view, of coping and defensive behavior.

In his analysis of observational learning, Bandura
(1971) emphasized attentional and retention processes, which
involved imaginal and verbal representational systems, and
motoric reproduction skills and reinforcement. Experimenta—
tion (Bandura, Grusec, & Menlove, 1966) has shown that
interference with the attentional and retention processes
decreases observational learning. Social learning theory
and research integrates more traditional theoriesiof
learning with the more recent emphasis on information
processing theories of learning, which in turn have examined
and clarified the nature of the processes which Bandura
outlined.

A number of investigators have studied the influence of

anxiety on learning and information processing. Arnold

32
(1960) and Lazarus (1966, 1968) emphasized the importance of
appraisal and reappraisal of threat in determining emotional
experience and expression. Lazarus (1966, 1968) argued that
there are two basic kinds of processes by which individuals
may cope with threat or anticipated harm. These are direct
actions and reappraisals of the situation. Reappraisal of
the threat is likely to be the predominant mode of coping
where direct actions are not possible. Reappraisal may
proceed from a (more) benign appraisal to a (more) threat-
ening appraisal, or from an initially threatening appraisal
to a benign appraisal. Reappraisal may be predicated on
objective, new stimulus evidence and therefore involve good
”reality testing" or it may represent a "defensive” distor-
tion of reality. A study by Speisman, Lazarus, Mordkoff,
and Davison (1964) intervened directly to alter the manner
in which subjects appraised or interpreted the events
portrayed in a stressful film. Three sound tracks were

created for a film titled Subincision which depicts crude

 

genital operations among Australian aborigines. The tracks
varied in their capacity to raise or lower autonomic and
subjective stress reactions of subjects viewing the film. A
”trauma" track increased stress reactions to the film, while
"denial" and "intellectualization' tracks reduced stress.
Essentially the same results were found by Lazarus and
Alfert (1964) when they modified the experimental approach
by changing the sound tracks into orientation passages which

were played before the subjects watched the film. The

33
reduction of stress in this manner was referred to as the
"short-circuiting of threat" and was employed by Lazarus,
Opton, Nomikos, and Rankin (1965) with another film
depicting wood-shop accidents and showed similar results.

In addition to the findings concerning the‘effects of
appraisal and reappraisal of threat as influenced by ”mental
sets” given to subjects, Speisman et a1. (1964), who
selected subjects characterized either as "deniers” or
"intellectualizers", also found an interaction, though not a
particularly strong one (Lazarus, Averill" 8 Opton, 1970),
between the effects of the two defense-oriented soundtracks
and these two defensive dispositions. The stress of
intellectualizers was reduced more than that of their denier
counterparts when they heard the intellectualization
soundtrack, whereas deniers ”preferred” the denial
soundtrack in terms of stress reduction.

To the extent that dispositional factors (Lazarus, et
a1., 1970) such as defensive style contributed to one's
"mood" at any given moment, the work of Bower (1981) and
Weingartner, Miller, and Murphy (1977) supported the
influence of mood on another sub—process within the
learning process, that of memory. Mood was induced by
imagination guided by hypnotic suggestion with college
students in the Bower study and by studying psychiatric
inpatients who cycled between states of mania and normality
in the Weingartner et a1. study. These studies showed a

mood-state-dependent (Weingartner et a1.) or an affect-

34
state-dependent effect (Bower) on encoding, storage and
retrieval of word lists, events, personal experiences, and
free associations to neutral words. Roth and Rehm (1980)
found direct effects of mood on the interpretation of
interpersonal scenes, especially ambiguous ones, in
depressed and non-depressed psychiatric patients.

In a review of anxiety research in educational
psychology, Tobias (1979) pointed out that there has been
little consistency in research findings on the interaction
between anxiety and instructional methods. Citing replica-
tion as a problem, Tobias offered an information processing
research model which hypothesized that anxiety can affect
learning at the preprocessing, processing, and post-
processing stages by impacting on the cognitive processes
mediating learning at these stages. At the preprocessing
stage, Sarason (1972) and Wine (1971) suggested that more
anxious students divide their attention between the demands
of the task and preoccupations with somatic concerns and
negative self-references. Less anxious students generally
devoted more of their attention to task demands and less
concern to task-irrelevant issues. The greater the
interference at this point, the smaller the proportion of
the instructional content available to be processed.
Therefore:

Any procedures that permit students to reinstitute

some segment of input reduce the potential

interference of anxiety at this stage. Such
operations as being able to rewind an audio or

video tape,being able to branch back to prior
segments of instruction, and comparable operations

35

should reduce this source of interference and

ought to be especially beneficial to the

performance of high anxiety students (Tobias,

1979, p.575).

At the processing stage, Tobias saw three factors as
interacting with the level of anxiety. These factors were
difficulty of content, reliance on memory, and organization
of the task. More anxious students generally did more
poorly than their less anxious counterparts with more
difficult content, tasks requiring greater reliance on
short- and intermediate-term memory, and less organized
tasks. The differences between more and less anxious
students were smaller or disappeared with less difficult
material, tasks requiring greater reliance on long-term
memory, and more organized tasks. Since Wolpe's (1958)
systematic desensitization, a variety of approaches have
been employed to reduce tension and anxiety in testing and
evaluative situations. Tobias (1979) categorized these
approaches in three groups: applied relaxation techniques;
self-control training techniques using guided rehearsal, in
which students are encouraged to confront a stressful
stimulus within the training program; and cognitive coping
techniques which focus especially on decreasing negative
self-references which occur to students in stressful situa-
tions.

Spielberger (1966) compared the performance of high-

and low-anxiety students in laboratory and real-life learn-

ing tasks. Performance of the high-anxiety group varied as

36

a function of the difficulty of the task and the stress of
the situation. These students generally performed better
than low-anxiety students cu: less difficult and less
stressful taskst Spielberger, Gorsuch, and Lushene later
developed the State-Trait Anxiety Inventory (1970) which
attempted to take into account the theoretical and practical
differences between chronic (trait) anxiety and relatively
situation-specific (state) anxiety. The ”state" form of the
STAI will be used in the present study to assess anxiety
experienced by medical students while observing a surgical
procedure.

Investigators of test anxiety (Sarason, Mandler 8
Craighill, 1952; Sarason 8 Palola, 1960) demonstrated that
performance of the highly test-anxious varied as a function
of evaluative stress. At low stress levels, highly anxious
subjects performed as well as those who were less anxious.
At higher stress levels, however, the highly anxious
performed at levels lower than the low-anxious or than
themselves when stress was low. These studies provided
further evidence of the Yerkes-Dodson (1908) "Law" which
described the curvilinear relationship between learning (or
performance) and the drive state or anxiety level of the
subject. In his analysis of this curvilinear relationship,
Easterbrook (1959) brought the concept of "range of cues
utilized” directly to bear on the learning-anxiety interac-
tion, concluding that " when the direction of behavior is

constant, increase in drive is associated with a reduction

37
in the range of cue use" (p. 183). Easterbrook defined
drive in this formulation in terms of physiological activa-
tion in response to a state of biological deprivation or
noxious stimulation. Green (1980) has clearly stated a
significant implication of Easterbrook's analysis:
Drive may either facilitate or inhibit
performance, depending on the importance of
peripheral cues for performance. Increasing drive
up to a point will lead to the elimination of
noncentral stimuli that are unimportant and
possibly distracting, but further increase will
narrow the focus to the point that necessary
central cues are being eliminated. Furthermore,
the level of drive at which the transition occurs

should be lower for complex tasks than for
relatively simple ones because, in the former

case, a wider range of cues may be necessary for

good performance (p. 44).
Seemingly contradictory findings, in which anxiety was found
to be associated with a broadened range of perception of
stimuli, were reported by Schmidt (1964) and $0150, Johnson
and Schatz (1968). Dusek, Mergler, and Kermis (1975, 1976)
found that low-anxiety children learned a central task
better than high-anxiety children but showed poorer learning
of incidental stimuli. These findings seem to support a
hypothesis offered by‘Wachtel (1967) that arousal has two
effects on attention and cue utilization: increasing the
range of stimuli scanned while simultaneously narrowing the
focus or depth of attention within any given area searched.

Problems also exist in viewing state and trait anxiety
as unitary concepts. Deffenbacher (1980) illustrated at

least two»dimensions of state anxiety which are differen-

tially related to performance. The dimension of worry,

38

which referred to "focusing of attention on concerns about
performance, consequences of failure, negative self-
evaluation, evaluation of one's ability relative to others,
and the like“ “L 112), consistently related inversely to
performance. Simply stated, as worry increased, performance
decreased. The dimension of emotionality, which referred to
”the affective-physiological experience generated from
increased autonomic arousal” (p. 112), showed less clear
effects on performance. Emotionality was sometimes unre-
lated to performance and sometimes decreased performance.

A further explication of the multidimensionality of the
concepts of trait and state anxiety was made by Endler
(1980L. Positing cognitive-worry' and emotional arousal
components in state anxiety and such facets of trait anxiety
as social evaluation and physical danger, Endler attempted
to integrate multiple dimensions of anxiety into a "person-
situation interaction model of anxiety” (p. 249). In
asserting his belief that person-by-situation interactions
were more important than either persons or situations with
respect to personality theory, Endler both reaffirmed the
complexity of the learning-anxiety relationship and offered

a promising model for further exploration of this area.

The Clerkship in Medical Students' Career Choice
To begin to understand the role clerkships, and
especially the surgical clerkship, play in the career

choices of medical students, it is important to consider

39
this issue within the developmental context in which it
occurs. Career choice patterns of medical students have
been a subject of growing interest to investigators in
recent years. In a presentation at the Sixteenth Annual
Conference on Research in Medical Education, Hutchins
(1977) stated: "There is a long line of decision links that
begin prior to entrance into medical school, continue
through medical school and into post-graduate education
culminating in the actual professional situation" (p. 387).
Hutchins' (1964) longitudinal study showed that career
choice patterns of medical students were quite changeable
and that these patterns of change were dramatic over the
years. A three-year study of University of California at
Davis medical students showed that students chose several
fields of interest early in medical school, mostly in
primary care areas such as family practice, and gradually
settled on aicareer choice by senior year (Brown and Burr,
1977). The Cooperative Michigan Longitudinal Study of
Medical Student Career Choice (1978), jointly sponsored by
Michigan State University's College of Human Medicine and
the University of Michigan and wayne State University
Schools of Medicine, generally concurred with the Brown and
Burr (1977) findings, showing early exploration of career
alternatives and convergence on choice in years three and
four. The Michigan Study (1978) found the highest level of
stability of choice over four years within the referral

specialties which include medicine, pediatrics and surgery.

40

In this study, data collected from 2,635 medical students
over their four years of medical school showed that 50% of
those who chose surgery at the end of their first year also
chose it at the end of year four. Of nine specialty areas,
only internal medicine/pediatrics and obstetrics/gynecology
were as high or higher in stability. Conflicting results
were found in a study of 1500 students in eight classes at
Ohio State University College of Medicine (Sachs, 1977)
which revealed a similar degree of stability of choice
across four major groupings: 1) primary care, including
family medicine, internal medicine, and pediatrics; 2)
operative, including ob/gyn, ophthalmology, otolaryngology,
and surgery;2n hospital-based, including anesthesiology,
emergency medicine, pathology, physical medicine, and
radiology; and 4) other, including preventive medicine and
psychiatry.

Wasserman, Yufit, and Pollack (1969) reported that over
50% of the students studied (N = 106) made no permanent
change in specialty choice (among fourteen specialties) from
freshman to seniOr year. The Sachs (1977) study, however,
reported a much lower degree of agreement. Slightly more
than 25% Ul==900) indicated the same choice of four major
groupings in their freshman year and internship year.
Further evidence of a high degree of change in career
preferences over the four years of medical school was found
by Bruhn and Parsons (1965) and Livingston and Zimet (1965).

The influence of specialty needs on career choices of

41

medical students is unclear. Williams (1976) and Spivey
(1976) held that the increase in medical school graduates
and a corresponding predicted oversupply in some surgical
disciplines would be as important or more important in
surgical career choices than other psychological,
sociological or educational factors. Mueller (1976)
concluded, however, that the career preferences of United
States medical graduates were ”undoubtedly related to
personal and individual choices and have little or no
relationship to manpower needs" (p. 22).

Concerning stability of choice in the senior year of
'medical school, Hutchins (1964) and Chapman (1976) reported
that one-third of students tend to change their minds one or
more times during their senior year. This brings into sharp
focus the importance of theiclinical clerkships, normally
undertaken in the third and fourth years of medical school,
in medical students' career choices. Burkefls (1979) outcome
evaluation of a clinical - level community medicine
clerkship indicated that the clerkship had a significant
impact on the career direction and attitudes of the medical
students who went through this program. Clerkships "assist
the student to gain perspective on the realities of various
types of medical and surgical careers and thus improve
career choices" (Mueller, 1976 p. 23). One of the
conclusions which Sachs (1977) drew from the large data pool
was that specialty choice became much more solid after one-

year or more in the operative clerkships. "The choice at

 

 

42
graduation on a detailed or a group basis shows 80% and 88%
agreement, respectively, with the choice as indicated at the
end of the first year of internship" (p. 219).

For the purpose of the present study, a specific aspect
of the surgical clerkship, that of time spent in the
operating room and the effect of the clerkship O.R.
experience on medical students' attitudes and career
choices,was especially relevant. Linn et a1. (1979) sought
to investigate these factors by surveying junior medical
students Ul==164) on interest in surgery before and after
their surgical clerkship. The percentage of students whose
interest changed positiveLy was 44%, while about 44%
remained about the same and 12% changed in a negative direc-
tion. The focus of the Linn et a1. study was not on those
students whose attitudes toward surgery remained essentially
unchanged but on those students ”for whom the clerkship
appeared to serve some definite function in attracting or
repelling them in terms of their interest" “L 153). Of
fifteen different clerkship experiences, time in the opera-
ting room was one of three experiences2 rated significantly
less favorably by students who changed negatively in their
interest in surgery than by those who changed positively.
Clerkship grades did not correlate significantly with
interest change. Almost half of the negative group changed
their career preference from surgery at the beginning of the

2The other two were time spent on the wards and
adequacy of supervision of workups.

43
clerkship, none was interested in surgery at the end of the
clerkship, and none entered a surgical residency later.

The Linn et a1. (1979) study did not investigate
specific aspects of the factor of time spent in the
operating room, such as quality and quantity, and the
relative influence of these on overall student evaluation of
the clerkship. Another study of a similar phenomenon,
however, found that senior medical students who spent 15% or
more of their preceptorship time in the emergency room
scored significantly lower on a simple self-report measure
of anxiety experienced in the EJL than did students who
spent less than 15% of their time in the emergency room
(Sivertson 8 Stone, 1980). The two groups were not
significantly different on self-reports of anxiety for
working in the emergency room prior to the preceptorship.

Finally, it is important to recognize that the surgical
clerkship affects the career choices and attitudes toward
surgery of both those students who later elect surgical
careers and those who do not. Calling surgery "the ultimate
audio-visual aid to learning" (p. 23), Mueller (1975) as-
serted that

The record indicates that two-thirds to three-

fourths of medical students elect careers in non -

surgical fields, and the surgical clerkship must
therefore prepare these individuals for their

fields as well as provide an introduction to a

surgical residency for the one-fourth to one-third

of students who elect surgery and/or its
specialties (p. 22).

44

Medical Students' Attitudes Toward Surgeons and Surgery

The literature on medical students attitudes toward
surgery is quite consistent in its findings. In a study of
141 male University of Colorado medical students, Zimet and
Held (1975) divided the students into psychiatrists, pedia-
tricians, family practitioners, internists and surgeons on
the basis of their freshman year specialty choice and then
re-surveyed the students in their sephomore and senior
years. Twenty-three percent of the students chose surgery
in their freshman year, 11% in their sophomore year, and 23%
in their senior year. ‘Using 117 adjectives from the Gough
and Heilbrun Adjective Check List (1965), Zimet and Held
obtained ratings of status, social attractiveness, and
similarity-to-self (Hi the five specified specialty
groupings. As was true within the other four specialty
groups, the surgery group viewed surgery as higher in status
than the other four specialty groupings. Surgery was given
a high status rank by all the other specialty groups except
psychiatry. In terms of social attractiveness, surgery
consistently ranked last, and in senior year all other
groups rated surgery significantly lower than did the
surgery group. The findings regarding the similarity—to-
self ratings revealed that "surgery consistently ranked last
in similarity-to-self for the student group as a whole.
Even those in the surgery group described themselves very
differently from the way they described the typical surgeon"

(p. 154). A later study by McGrath and Zimet (1977)

45

confirmed these results for female medical students,
although the percentage of female students choosing surgery
as a career specialty was much lower than that of male
students. Gough (1975) also showed that female medical
students and physicians differ from men in expressing less
preference for surgery and urology and more for obstetrics
and gynecology. Matheson and Smith (1977) explained such
sex differences in a‘historical context. They stated:

Females have not entered the surgical specialties

in any significant numbers perhaps because there

is some feeling among female medical students that

there is a bias in favor of males in that

specialty. Of the four students who listed

difficulty in getting a residency as the reason

for choosing a specialty other than their

preferred one, all four were female and all four

indicated surgery as their preference (p. 550).

Matheson and Smith (1977) also examined the
relationship between specialty preference and specialty
choice. They found that surgery was more preferred than
chosen, and related this to the low ranking of surgery in
terms of perceived demand over the next ten years. They
also investigated the relationship between specialty
preference/choice and the personality variable intolerance
of ambiguity (defined as a tendency to be threatened by
ambiguous or unstructured situations). Surgery and
obstetrics-gynecology were perceived as highly structured
and psychiatry as highly unstructured. Their hypothesis
that students who preferred but did not choose surgery would

have more tolerance for ambiguity than students who actually

chose surgery was supported.

46

Bruhn and Parsons (1964), in investigating medical
students' attitudes toward surgeons, found that medical
students viewed surgeons as "domineering and arrogant,
aggressive and full of energy, and mainly concerned with own
prestige" (p. 43). These attitudes contrasted sharply with
those toward the general practitioner, whom medical students
view as patient, friendly, sensitive, and deeply interested
in people.

De Palma, Izant, Jordan, Holden, and Sheehan (1974)
described a surgical clerkship program consisting of an
introductory five-week clerkship at the beginning of the
third year and a later core clerkship of two months, the
latter having both cognitive and affective goals as well as
psychomotor goals. They concluded that the core experience
was more important in influencing career choice than
introductory exposure. They reported an increase in the
proportion of students applying for straight surgical
internships and stated that "negative attitudes expressed by
students about surgeons as physicians are now notably
absent. The fact that many students now have their first
major clinical experience on a surgical service probably

relates to more positive student attitudes" (p. 920).

Interpersonal Process Recall (IPR)

 

The IPR model and its use in the present study was
described in the Definition of Terms section at the end of

Chapter One and is further described in Chapter Three. This

47
section reviews some of the significant literature relevant
to the model, especially that pertaining to improving
medical students' interviewing skills.

The model was conceived in 1962 at Michigan State
University by Kagan and his associates (Kagan, Krathwohl 8
Miller, 1963; Kagan 8 Krathwohl, 1967). It has been used
with a variety of groups in a variety of settings to improve
interaction: with counselors and clients (Goldberg, 1967;
Kingdon, 1975; Tomory, 1979); with teachers in urban schools
(Burke 8 Kagan, 1976); with residence hall assistants
(Dendy, 1971) and college students (Archer 8 Kagan, 1973);
with prison counselors (Grzegorek, 1970) and inmates
(Singleton, 1976). Positive effects of application of the
model, such as improvement in interviewing skills, in
affective sensitivity, and self- actualization, in client
self-exploration and in empathy skills as measured by such
measures as the Counselor Verbal Rating Scale (Kagan 8
Krathwohl, 1967), the Affective Sensitivity Scale (Danish 8
Kagan, 1971), the Personal Orientation Iventory (Brammer 8
Shostrom, 1963), the Wisconsin Relationship Orientation
Scale (Steph, 1963), and the Carkhuff Accurate Empathy Scale
(Carkhuff, 1969). Each drill sergeant in the U.S. Army
currently completes an IPR course as part of basic drill
sergeant training and the model has been translated into
Swedish, Danish and German (Kagan, 1982).

Jason, Kagan, Werner, Elstein, and Thomas (1971)

adapted the IPR model for use with medical students by using,

48

simulated patients, actors trained to play patients in
various conditions of health or illness and with varying
interpersonal styles. Significant gains in interviewing
skills and in sensitivity to interpersonal messages using
this approach (Resnikoff, 1968; Werner 8 Schneider, 1974)
led to the introduction of "stimulus vignettes,‘I in which
videotaped actors and actresses simulated one side of
various emotionally impactful interpersonal situations
(Kagan 8 Krathwohl, 1967; Kagan 8 Schauble, 1969; Danish 8
Brodsky, 1970). New sets of vignettes were created to
simulate potentially stressful interactions in specific
contexts, e.g. for teachers and medical students, and these
were incorporated into training programs such as that for
Michigan State University College of Human Medicine students
reported by Werner and Schneider (1974). The demand for
such training in interpersonal skills and its importance in
medical education and health care delivery was discussed by
Kagan (1979).

In a personal communication to Kagan, Coppola and
Cochran (1979) outlined their findings about the incidence
of negative reactions to surgical stimuli among medical
students entering their surgical clerkships and suggested
that the IPR method might be adapted to assist students in
reducing emotional and physiological responsiveness and to
facilitate early learning in surgery. This collaboration

resulted in the Embelton (1981) study and the current study.

49

The Embelton Studyg(l98l)

 

Embelton's subjects were twenty-three male and twenty-
five female students from the Colleges of Human and
Osteopathic Medicine at Michigan State University.
Treatment and control students were matched according to
year of training, experience in surgery, and medical school
curriculum (Track One designating a more traditional
approach and Track Two a small-group and individual learning
approach). Treatment consisted of two sessions in the IPR
laboratory at Michigan State University for each treatment
group student. In these sessions, the students viewed
videotaped vignettes of actual and simulated operating room
scenes and recalled their reactions with an inquirer while
viewing the videotape of themselves viewing the vignettes.
They also reviewed analogue records of their physiological
reactivity during the recall.

Matched pairs of treatment and control group students
then viewed an actual operation together and responded to
two outcome measures, the Operating Room Experience
Inventory and the Apprehension to Surgical Procedures
Questionnaire. Embelton found no significant differences
between his groups on either of these measures.

Embelton's vignettes were five to fifteen seconds in
length. 'The treatment consisted of two IPR lab sessions.
The current study was an attempt to improve on the Embelton
study by using new and longer vignettes, adding an instruc-

tional component to the end of the second laboratory

50
session, and adding to the treatment a recall of the student
viewing an actual surgical procedure. Three groups were
used in the current study in an attempt to rule out
alternative hypotheses, such as positive effects of actual
or videotape viewing of operations, if significant results
were found. Embelton's outcome measures were further
objectified and improved and several other measures were
added to expand the scope of the investigation. The
specific methods and procedures employed in the present

study are described in the following chapter.

CHAPTER III

METHODS AND PROCEDURES

Population

 

Medical student participation in the project was
invited through a series of three letters circulated to all
first- and second-year students in the College of Human
Medicine (CHM) (n= 200) and the College of Osteopathic
Medicine (COM) (n= 250) athiChig n State University in the
spring of 1980 (Appendix A). The first two letters outlined
the project in general terms and indicated a tentative time
commitment that students could expect to give over the
summer of 1980. The third letter emphasized that the
project was especially pertinent for students with little or
no surgical experience and that this was an opportunity for
them to gain experience. The project was approved by the
University Committee on Research Involving Human Subjects as

well as by the Medical School Research Office.

Sample

Sixty-three students returned participation forms
indicating their interest in the project as well as the
extent of their surgical experience. Two of these students
(one male, one female) were unable to participate due to
changes in their summer schedules. Of the sixty-one

51

52
students vflu: were able to participate, forty-five students
completed all phases of the project. The following table
contains a description of characteristics of those who

completed the project and those who did not.

Table 3.1: Participant Characteristics

 

Did not Complete Completed
Project (n=16; 26%) Project (n=45; 74%)

 

Male 3 (7%) 40 (93%)
Female 13 (72%) 5 (28%)
COM (Osteopathic) 8 (21%) 30 (79%)
CHM (Allopathic) 8 (35%) 15 (65%)
lst Year 12 (25%) 36 (75%)
2nd Year 4 (31%) 9 (69%)
Mean Age 24.9 (Range 26 (Range
22-30) 22-39)

 

Whereas the "typical” student who did not complete the
project was a female first-year student, the typical student
who completed the project was a male first-year osteopathic
student. Completion of the project depended to a great
extent on time availability and scheduling, because the out-
come phase of the project involved sets of three students,
one from each group, observing the same operation.
Consistent contact with students throughout the summer was

required. Although the scheduling and design requirements

53
of the project, especially the outcome phase, were a factor
in the incomplete participation of sixteen students,
additional possible factors, perhaps related to the
differential experimental mortality of male and female
students and of osteopathic and allopathic students, will be
discussed in Chapter Five.

Students interested 1J1 participating returned the
participation form (Appendix B) which provided demographic,
surgery-related experience, and scheduling information. An
"experience score" was obtained for each type of surgical
experience listed on the participation form. The highest
score was assigned to assisting in an operation in the
operating room and the lowest score to observing an opera-
tion in a physician's office (Appendix B). This gradation
of scores represented an estimate of the relative
physiological-emotional impact of these experiences on
students and was determined through discussion with a small
group of non-participating first and second year medical
students. Students were then ranked by total experience
‘scores. All students who returned participation forms were
contacted and the project was explained. Students were told
that the purpose of the project was to investigate medical
students' reactions to surgery and that they would be
divided into groups which would all have the opportunity for

the same experiences, but in different sequences.

54

Design
The experimental design employed in the study

represented a three-group posttest-only control group design

graphically represented in Figure 3.1.

Figure 3.1: Design of Study

 

R X1 0
R X2 0
R O

R indicates random assignment,
X indicates treatment, and

0 indicates outcome

 

This was a "true experimental design" in which random
assignment of subjects to treatment conditions suffices
to control for initial intergroup biases without a pretest,
”within the limits of confidence stated by the tests of
significance” (Campbell 8 Stanley, 1963, p. 25). Subject
mortality, consisting of non-participating or only partially
participating subjects whose data are not represented in the
final analysis, can be a problem in this design, especially
if there is differential mortality from the treatment
groups. As indicated in Table 3.1 above, male students and
osteopathic students were disproportionately overrepresented

in the group which completed the project compared to the

55
group which did not complete it. Although the same
approximate number of students in each group did not
complete the project (five in Groups One and Three, and six
in Group Two), this non-completing group included a
disproportionately large number of females and allopathic
medicine students. A diagrammatic representation of the

experimental procedures is presented in Figure 3.2.

Treatment
Assignment to Experimental Conditions

Based on their ranking by assigned experience scores,
students were divided into threeigroups--high, medium and
low experience. The members of each group were then
randomly assigned, by means of a random numbers table to the
two treatment conditions and the control condition. This
method of assignment was intended to control the experience
variable by using it as a blocking variable, but this
arrangement was impossible to implement in the outcome phase
of the project due to scheduling difficulties. It was
frequently necessary to team up three students, one from
each treatment group, from different experience groups.
This necessitated the use of experience as a covariate in

the data analysis rather than as a blocking variable.

Two-Phase Laboratory Experience
Introduction
The initial treatment portion of the study for Group

One consisted of two sessions in the IPR Lab at Michigan

56

Figure 3.2: Diagram of Experimental Procedures

 

RANDOM ASSIGNMENT

Experimental Experimental Control
Group One Group Two Group
n = 15 n = 15 n = 15
IPR Lab
A. Training
Session 1
Individual
IPR Lab Observation No
B. Training D. of an E. Treatment
Session 2 Operation
O.R.
C. Training
Session

F. A Common O.R. Experience
in "Triplets”

G. Outcome Measures

 

57
State University, each session lasting approximately one and
a half hours. The students in the full—treatment group were
scheduled for two sessions in the laboratory. The two
sessions were normally scheduled about a week apart, but
this time period varied from four days to two weeks. ‘When
the student arrived for his/her laboratory session, s/he was
met by an inquirer. The inquirers in the project were three
paid male counseling psychology doctoral students who had
been trained in the I.P.R. method, the physiological wiring
procedure, and the specific application of the IJAR. method
to this project. They followed standardized procedures

outlined in Appendix C.

Physiological Wiring Procedure

The medical student was instructed to wash his/her
hands and forearms with warm water and soap. This prepared
the surface skin for the application of the electrodes to
measure heart rate and skin conductance. The student was
then seated in a specially wired chair in the subject room.
The room temperature was maintained at 72° - 74°. The
inquirer then briefly explained the laboratory'procedures
and proceeded to connect the student to the physiological
recording devices. Figure 3.2 describes the floor plan of
the I.P.R. Laboratory suite at M.S.U. A brief description of
the electrode placement procedure and the physiological

recording equipment and computer equipment follows.

58

Figure 3.3: Floor Plan of IPR Laboratory Suite

 

 

 

 

 

 

 

 

 

 

KEY

A.
B.
C.

E.
F.
G.

H.
I.
J.
K.

 

' :l c

H

 

 

 

 

 

 

 

 

 

 

 

3:2:1

 

 

Subject seated here while viewing vignettes
Mirror reflecting vignette on C

Camera behind one-way mirror videotaping A
and B while subject views vignettes

Grass model 7WC8PA strip chart recorder
Camera videotaping physiological readout
Videotape recorder and special effects
generator

Inguirer seated here during recall

Subject seated here during recall
Split-screen monitor

Videotape recorder controlled by subject
during recall

59

Two Beckman electrodes were placed on each arm, one
electrode on the hypothenar eminence of the palm and one on
the upper inner forearm. These electrodes measured skin
conductance. Three pregelled disposable EKG electrodes were
used to record heart rate expressed in beats per minute.
One of these electrodes was placed on each inner wrist just
above the hand. The third electrode was placed on the
outside of the lower leg and functioned as a ground. The
lead wires from these seven electrodes were inserted into an
input connection box attached to the arm of the subject
chair. Respiration was recorded by means of a rubber
bellows placed around the studentls chest. The bellows was
linked by a rubber tube to a volumetric pressure transducer
which fed an electrical signal into a Grass strip chart
recorder (model 7WC8PA; Grass Instrument Co., Quincy,
Mass.). A Hagfors Bridge (Hagfors, 1966) received the shin
conductance signals and fed these intovthe Grass recorder.
The Grass recorder also received signals from the heart rate
electrodes and thus recorded the student's respiration,
heart rate and skin conductance and printed these while the
student watched the vignettes. A Digital PDP 11—34
computer recently added to the laboratory could be activated
to sample and store incoming data from theiGrass recorder.
Because this interface was in an early stage of development
in the laboratory, this computer sampling and storage could
be done on only eleven students. Of these eleven, three did

not complete the project. Of the eight students who did

60
complete the project, computer data were obtained for three
vignettes for six of the students and for one and two

vignettes respectively for the other two students.

Viewing of Vignettes

As the electrode attachment procedure was being
completed by the inquirer, a second member of the research
team calibrated the physiological recording devices which
were housed in an adjacent room. The inquirer stayed in the
subject room with the student until calibration was
completed. The inquirer reminded the medical student to try
to become as involved as possible with the vignettes and
then left the subject room. The medical student was then
shown the appropriate series of vignettes. The series of
vignettes used in lab session one began with an introduction
by the author, in which he encouraged the students to become
as involved with the vignettes as possible. This first
series consisted of twelve vignettes, and the second series,
used in lab session two, consisted of eleven vignettes.
Nine of these vignettes had been used originally in
Embeltonwsl979 study, while the remaining fourteen were
produced specifically for the current study with a goal of
producing more impactful content and better color reproduc-
tion. Eight of the twenty-three vignettes were inter-
personal in nature, while fifteen were videotape segments of
actual surgical procedures. Typescripts of these vignettes

are found in Appendix:D. The fourteen new vignettes were

61

produced by the technical supervisom of the project with a
Sony video camera (Model DXC-1610) and Sony color videotape.
Portions of these videotapes were spliced on a Sony Editing
System (Model RM-400) to produce the two sets of vignettes.
The vignettes varied in length from twelve seconds to five
minutes, eighteen seconds, and were separated from one
another by a twenty-second rest period.

While the student was watching the vignettes, a Sony
video camera (Model AVG-3200) placed above the Grass
recorder recorded the student”; physiological responses to
the vignettes. A remote-controlled marking device was used
to distinguish the vignettes from the rest periods on the
Grass recorder printout. While the first camera was
recording the movement of the pens on the Grass recorder, a
second camera, placed as inconspicuously as possible,
recorded the studentfs face and upper body through a oneway
mirror in the subject room. This camera also recorded the
vignette which the student was watching by means of a mirror
placed above and behind the student's head which reflected
the vignette, as shown in Figure 3JL. The simultaneous
inputs from each camera were filtered through a special
effects generator allowing all three pieces of feedback
information, the student watching the vignette, the vignette
reflected in the mirror, and the physiological recording, to
be recorded simultaneously on the same 1/2-inch Sony

recording tape for use during the recall.

62

Recall

In the first laboratory session, the student watched
the first four vignettes of the first series. An IPR recall
of the student's responses to these vignettes was then
conducted by one of the inquirers in order to familiarize
the student with the recall process. The student was asked
to recall and discuss cognitive, emotional and physiological
reactions to the vignettes. The paper readout from the
Grass recorder was used to facilitate the recall process.
The student viewed the videotape on the playback monitor in
the subject room. 'The right half of the screen displayed
the physiological record as it was unfolding, and the left
displayed the studentfs face while watching the vignette as
well as the vignette itself, reflected in the mirror over
the studentfis head. The student was encouraged to stop the
tape whenever desired, but especially at the end of each
vignette, to discuss personal reactions. The open,
exploratory, student-controlled atmosphere of the IPR recall
was maintained. This "mini-recall," after the first four
vignettes of the first series, was built into the design to
familiarize all the students with the recall process, but it
was especially geared to the needs of the osteopathic
students. College of Human Medicine students had already
had an IPR-based doctor-patient relationship course and were
at least familiar with audiotape recalls, if not with the
videotape method used in the laboratory. The osteopathic

students had not had this prior exposure to IPR, however,

63
and it was felt that the'Hnini-recall" would be«especially
helpful to them in gaining as much as possible from the
recall process. Following the mini-recall, the inquirer
left the subject room, the medical student watched the
remainder of the vignettes, and a recall of the student's

reactions to these later vignettes was then conducted.

Instructional Component

The second session of the two-phase laboratory
experience was similar to the first except that the second
series of vignettes was used and the student viewed a short
instructional videotape at the end of the session. This
instructional component was added to the treatment on the
basis of a possible interpretation of Embelton's non-
significant results. 11:13 possible that through the IPR
lab sessions Embelton's medical students became more aware
of their reactions but still felt a lack of control over
them. This felt lack of control may have interfered with
their observational performance in the operating room. The
addition of an instructional videotape offering concrete
suggestions on coping with reactions to unpleasant stimuli
in the O.R. would perhaps address the need for control over
the reactions which the student experienced. The videotape
used was narrated by the Director of Surgical Education at
M.S.U. and was excerpted from a videotape entitled Learning

on the Surgical Clerkship--in the O.R. (Doran, Cochran,

 

English, Alexander, 1979). 'The typescript of the segment

64

used in the study is found in Appendix E.

Hospital Experience

 

Introduction

The arrangement of the hospital experience phase of the
project involved extensive contact with medical students,
surgeons and O.R. personnel, especially in the scheduling of
students to be videotaped in the ORR. and scheduling of
students to observe operations. The technical supervisor of
the project, a surgical orderly and doctoral student in
biology, was instrumental in the successful accomplishment
of this phase of the project.

Approval to conduct the hospital phase was sought from
four hospitals in the Lansing area. Two hospitals did not
approve, one indicated concern for patient safety with the
use of videotaping equipment in the O.R. Of the two
hospitals which approved, one did not approve until late in
the outcome phase of the project, and it was judged
impractical at that point to incorporate a new experimental
site. The entire hospital phase of the study, therefore,
was conducted at Ingham Medical Center in Lansing. Ingham
Medical Center is a community-oriented, non-profit teaching
hospital with 700-plus beds. The multiple-specialty
surgical suite has eight operating rooms, six of which are
similarly equipped. The other two can function as general
purpose OJLs but are also specially equipped for heart

surgery.

65

To enlist the cooperation and participation of surgeons
in the project, Dr. Edward Coppola sent letters to several
area surgeons who practice at Ingham Medical Center
(Appendix F). Eighteen surgeons participated, allowing
medical students to observe and/or be videotaped in the GAL
These surgeons did not know the specific purpose of the
research. Some interacted with the students more than
others. Level of interaction ranged from one surgeon who
spent time showing the patient's x-ray to the students and
discussing the case to surgeons who said little to the
students. The employment in the outcome phase of the
project.of "triplets"--groups of three students, one from
each group--was partly an attempt to control for this
surgeon variability.

Three distinct experimental procedures were conducted
at the hospital. The first of these involved the third
treatment experience for Group One students following their
two laboratory sessions. Along with the instructional
videotape at the end of the second laboratory session, this
initial hospital experience comprised a significant addition
to Embelton's treatment. This addition consisted of
videotaping and conducting a recall of the Group One
student's reactions to his/her first OER. observational
experience in the project.

Group One Recall of Observation of Operation
The following standardized procedure was followed in

arranging and implementing this first hospital treatment

66

experience of Group One students in the O.R.

1.

Operating room schedules were obtained from the
O.R. head nurse as far in advance as possible.
The day's schedule was usually printed the
preceding afternoon, sometimes on Friday for
Monday.

The technical supervisor of the project and the
author chose possible operations to be used on the
basis «of six criteria: (1) surgeon
cooperativeness; (2) probable use of general
anesthesia; (3) a significant incision; (4)
probable length in time'of one to two hours; (5)
probability of patient willingness to sign the
release form for videotaping (slight, for example,
in hysterectomy and mastectomy cases); and (6)
relatively low probability of patient mortality.

The technical supervisor approached patients and
asked them to sign release forms for videotaping
(Appendix G). In most cases, patients were very
cooperative.

The author maintained periodic telephone contact
with medical students to keep updated on their
summer schedules. Students who might be available
on a given day were called to conf1rm a time to be
videotaped in the ONE. and to have a recall of
their reactions following their observation of the
surgery. As the project progressed and it became
clear that experimentally appropriate operations
would be quite readily available, students
frequently specified a good day in advance and
were then notified the evening prior to their day
of the exact time of the surgery they would
observe. Students were asked to arrive in the
surgical suite one-half hour before the scheduled
start of the surgery.

When the student arrived at the surgical suite,
s/he was met by the author and the technical
supervisor and shown to the locker room to obtain
surgical attirer("scrub suit” consisting of cap,
shirt, pants, mask, and shoe covers). The student
changed and was then given brief instructions
regarding sterile procedures in the OLR. The
student was told the surgeon's name, the patient's
age and sex, and the nature of the procedure to be
performed. The student was instructed to observe
and did not ”scrub in."

Group Two

The

67

The technical supervisor got confirmation from the
scheduled surgeon for the student to observe the
first part of the operation and for videotaping.

The student observed the first half hour of the
operation, usually entering the O.R. just prior to
the insertion of the endotracheal tube and the
induction of anesthesia. This enabled the student
to view those aspects of surgery consistently
identified by students in the Coppola-Cochran
survey and in Embelton's study as the most
tension-producing: the induction of anesthesia,
final prepping of the patient, the incision, and
at least the initial portion of the surgery
itself. The basic rule followed in placement of
the student in the CLR. was that the student
should get the best vantage point possible while
avoiding sterile .areas. Surgeons frequently
cooperated in giving the student the best possible
View.

The technical supervisor videotaped the student
the O.R. and the surgical procedure for about 1/2
hour using a Sony color camera (Model DXC-l610)
and a cassette videotape recording deck. This
equipment was wiped with an antiseptic solution
prior to its use in the O.R.

The student then left the O.R. and was met by one
of the three inquirers employed in the study. An
attempt was made to arrange schedules so that a
given student had the same inquirer for all three
recalls, the two in the laboratory and the one in
the hospital, though this was not possible in all
cases. In most cases, after the medical student
had changed back into his/her street clothes, the
inquirer and the student carried the videotape
cassette to the Michigan State University Clinic
in the Professional Building of Ingham Medical
Center and conducted the recall in one of the
examining rooms there using a Sony color monitor
and a cassette videotape recorder. In two cases,
scheduling did not permit the recall to be held
immediately following the videotaping. In both of
these cases the recall was conducted in the IPR
laboratory at M.SJL, one later on the same day
and one three days later.

Observation of Operation.

second experimental procedure conducted at the

hospital was the observation of an entire operation by each

68

Group Two student. Nineteen Group Two students observed
operations. At the beginning of the hospital phase, the
investigator was uncertain about how easily accessible
operations would be. Since the number of operations might
be limited, it was initially decided to schedule pairs of
Group Two students to observe operations together. This was
done with the first two operations. It then became apparent
that accessibility to operations wouLd make it possible to
schedule students to observe singly, and this was done
thereafter. In almost all cases, the investigator and/or
the technical supervisor were in the O.R. to note any
significant anecdotal data.

Standardized procedures similar to those outlined above
for Group One students were carried out in arranging these
experiences for Group Two students, except that GroupuTwo
students observed for a longer time, were not videotaped,
and had no recall. Observation times for Group Two students
averaged one hour nineteen minutes, ranging from forty-five
minutes to two and one-half hours. The experimental goal
had been to have students observe for about one and one-half
hours, but some surgical procedures were longer and some
were shorter. In one case, a Group Two student, after
observing an operation for one hour, on his own initiative
asked a surgeon if he could observe a heart operation which
had just begun. The surgeon agreed, and the student
observed the operation for six hours. This time period was

not included in the computation of the average observation

69
time.

The primary reason for the inclusion of Group Two in
the present study was the anticipation of an alternative
explanation of significant results if these were found. Had
Embelton found significant differences between his groups in
the hypothesized direction, a possible explanation would
have been the fact that the full-treatment group had prior
surgical experience of a sort in viewing the surgical
vignettes, and that this additional experience might have
improved their performance regardless of the recall, the
essence of the IPR model. The inclusion of a second
treatment group which observed an actual operation was an
attempt to avoid this competing hypotheses. Although total
treatment time for Groups One and Two varied from an average
of four hours for Group One to an average of about one and
one-half hours for Group Two, Group Two nonetheless did have
more surgical observation time than Group One prior to the
outcome phase of the study (one and one-half hours compared
to one-half hour for Group One). The use of a control group
in this study served the same purpose as it had in
Embelton's study, that of representing the current reality
of the medical school curriculum in which there is no formal
provision for surgical experience prior to the surgical

clerkship.

(LR. Observation by "Triplets"
The third experimental procedure conducted at the

hospital consisted of sets of three students (”triplets"),

70

one from each group, observing an operation together and
then responding to the outcome measures. As more and more
students completed this final phase of the project and the
available student pool decreased, it became increasingly
difficult to synchronize schedules to obtain new triplets.
This was the primary reason why fifteen students in each
group completed the project when there had originally been
at least twenty students in each group. Attempts were made
throughout the fall of 1980 to assemble more triplets, but
this could be done only on Saturdays in most cases due to
student class schedules, and there was usually only a light
O.R. schedule of emergency operations on Saturdays, if any.

The three students in a triplet were instructed to
arrive at the hospital one-half hour prior to the scheduled
start of surgery and to wait in the main lobby of the
hospital. The students were met there by the investigator
and given an instruction sheet (Appendix H) outlining the
procedure to be followed. The students then changed into
scrub suits and entered the O.R. just prior to the patient's
entry.

They remained in the O.R. until the surgery was
completed. The technical supervisor was in the CLR. in all
these cases in order to record the correct answers to the
Operating Room Experience questionnaire for each surgical
procedure for use in correcting the students' question-
naires. The investigator was also present in most cases to

record anecdotal data, to insure independent observation,

71
and to assure that each student had equal opportunity for
observation. The goal had been to have these triplets
observe an entire operation lasting about one and one-half
hours. Due to the relative unpredictability of time in
surgical procedures, actual observation times ranged from
forty minutes to one hour thirty-five minutes, the mean time
being slightly over one hour. One student in the second
triplet was late in arriving at the hospital, so this
triplet observed the last part of the scheduled operation
and the beginning of another. When this triplet completed
the outcome measures, the author indicated which questions
on the Operating Room Experience questionnaire they should
answer for the first operation and which for the second.
The students left the CLR. following the operation, changed
clothes and proceeded with the author to a conference room
in the hospital to complete the outcome measures. In two
cases this was done in a quiet area of the hospital library.
All triplets completed the outcome measures in thirty to
forty minutes. This completed the treatment and outcome

phases of the project.

Instrumentation
Introduction
Eight outcome measures were used in this study. They
were:
1. State-Trait Anxiety Inventory (STAI Form X-l)

2. Operating Room Experience questionnaire (ORE)

3.

4.
5.
6.
7.
8.

72

Apprehension to Surgical Procedures
Questionnaire (ASPQ Form E)

”Surgeon" Semantic Differential

"Myself in the O.R." Semantic Differential
Specialty Questionnaire

"Self” Semantic Differential

Impression Paragraph

Copies of these measures are found in Appendix I. These

measures were divided into the following five dependent

variable groupings:

l.

4.

5.

Measures of Emotional/Physiological Reactivity
a. State-Trait Anxiety Inventory

b. Apprehension to Surgical Procedures
Questionnaire

Learning (Observation) Measure

a. Operating Room Experience Questionaire
Attitudinal Measures

a. "Surgeon" Semantic Differential

b. "Myself in the O.R." Semantic Differential
C. "Self” Semantic Differential

Medical Specialty Questionnaire

Impression Paragraph

Each grouping will be discussed below, with specific

reference to the individual measures within each group.

Measures of Emotional/Physiological Reactivity

The state form of the State-Trait Anxiety Inventory (A-

State, Form X-l; Spielberger, Gorsuch, Lushene, 1970) was

73

used to measure the general level of state anxiety which
medical students experienced in the (LR. This measure
operationalized anxiety as a dual concept including both
traitanxiety, which refers to relatively stable individual
differences in anxiety proneness, and state anxiety, which
refers to a transitory emotional state or condition charac-
terized by subjective, consciously perceived feelings of
tension and apprehension and heightened autonomic nervous
system activity. Only the state form of the inventory was
used in this study, since the primary issue was the experi-
ence of anxiety by the students in the OgR. rather than
their experience of anxiety in general. The instructions on
the form were modified, in accordance with suggestions in
the test manual, to pertain to the time when the student was
in the O.R. Several items were also changed to past tense.
The STAI was the only standardized instrument used in the
study. The validity of the STAI was developed over a six-
year period with seven different samples of undergraduates.
The test is highly correlated with other standard measures
of state and trait anxiety (Spielberger et al., 1970).
Since anxiety states are by definition transitory in nature,
internal consistency measures of reliability are more mean-
ingful than test-retest measures. Spielberger et al. (1970)
reported Cronbach alpha coeffiCients ranging from .83 to
.92 for the STAI Form x-l, indicating sufficient internal
consistency. The computed alpha reliability coefficient for

the STAI in the present study was .813. Higher anxiety was

74
indicated by higher scores on the STAI.

A measurement of medical students' reactions to
specific stimuli in the operating room was obtained by the
Apprehension to Surgical Procedures Questionnaire (ASPQ,
Form E». This questionnaire was adapted from the form used
by Embelton and originally developed by Coppola and Cochran
to assess medical student reactions to specific stimuli in
the operating room during their surgical clerkships. The
present form obtained information about the nature, extent,
intensity, and duration of unpleasant physiological and
emotional reactions which the student may have experienced
in the OJL, as well as methods the student used to cope
with these reactions. The questionnaire also asked students
to identify specific stimuli to which they were physically
and/or emotionally sensitive while they were in the opera-
ting room. Students were asked to check one of the
following categories for each of 36 specific stimulus items:
"Didn't bother me," ”Bothered me a little," "Bothered me a
lot," and "Does not applyu" 'The allocation of points was

done as follows:

Didn't bother me

Bothered me a little

II
C N H O

Bothered me a lot

Does not apply =

A total score and an average score, based on the number

of items which the student indicated were bothersome, were

computed for each student and yielded an index of the

7S

student's reactions to the operation observed.

Learning (Observation) Measure

Rather than attempting to measure learning in a broad
sense, the present study attempted to assess a specific
component of the learning process, that of observation.
Devising a suitable instrument for this purpose was
complicated by the fact that different sets of students
("triplets”) observed different operations. Coppola,
Embelton and Cochran (1979) encountered the same problem in
Embeltonfis study, and constructed an instrument called the
Operating Room Experience inventory (O.R.E.). The O.R.E.
asked fifteen questions of the medical student, fourteen of
which were short answer and one of which was multiple choice
in nature. In Embelton's study, the operating surgeon
decided which of the two students who had observed his
operation did better on the O.R.E. In the present study,
the O.R.E. was adapted in an attempt to increase its
objectivity and standardization across operations and its
face validity. Questions were stated in a "yes-no" or
multiple choice format whenever possible. This format
comprised eight of the questions in the final form. The
remaining twelve questions required single number or short
written answers. An attempt was made to minimize the possi-
bility'of a positive bias toward better writers among the
medical students. The O.R.E. includes questions about

patient and surgeon characteristics, specific surgical

76
procedures, instruments and equipment, anatomy and OJL
staff. The face validity of the instrument was evaluated by
three academic surgeons at Michigan State University not
connected with the study, and they agreed that a medical
student scoring 80% on the questionnaire would have been
”very observant in the OJL" Increasing the number of items
from fifteen in Embelton's study to twenty in the present
study increased the potential variability of scores,
although Embelton used only dichotomous scores anyway (a one
or two, based on the surgeon's rating of which student had
performed better). In an attempt to utilize this increased
variability and increase the chance of finding intergroup
differences, the three OJRJLS completed by the different
triplets observing operations were scored blindly by the
technical supervisor of the project based on her completed
OJLE. for each of these operations. These scores were used
in the analysis as indices of the medical students' observa-

tional skill during the operation.

Attitudinal Measures

 

The attempt in the present study to measure attitudes
of medical students was a result of two factors: (1) the
possible relationship between medical students' unpleasant
reactions to operating room stimuli and their attitudes
toward surgeons and surgery; and (2) the possibility that
attitudinal differences between the three groups existed

despite a lack of significant results on the State Anxiety

77

Inventory and the Operating Room Experience Inventory.
These latter possible differences pertained to medical
students' perceptions of and attitudes toward themselves in
general and themselves in the operating room. These
differences do not always manifest themselves on the State
Anxiety Inventory or the Operating Room Experience
Inventory, but might.be a subtle yet measurable effect of
the self-scrutiny and self-awareness fostered in the IPR
recall process, both in general and in relation to surgery.
Three attitudinal measures were therefore incorporated into
the present study to attempt to uncover any such differences
that might exist among the groups.

The type of instrument chosen to explore this area was
the semantic differential (Osgood, Suci, 8 Tannenbaum,
1957). In addition to possessing a good research record of
measuring attitudes and attitudinal change (Osgood, et al.;
1957; Staats & Staats, 1958; Tannenbaum, 1966; Williams,
1966), the semantic differential offered ease of administra-
tion, scoring and analysis. The essence of a semantic
differential instrument is the juxtaposition of words,
usually adjectives, with polar meanings to which the subject
is asked to respond by indicating the degree to which s/he
feels.a given concept is related to’one or the other word,
e.g.:

very quite only neutral only quite very
KIND closely closely slightly or equally slightly closely closely CRUEL
related related related associated related related related

The first step in constructing semantic differential

78

instruments was to select the concepts which would be rated
with the bipolar adjectives. In the present study, as
stated above, the medical students' attitudes which were of
interest were those toward: (1) surgeons and surgery; (2)
the medical student him/herself in general; and (3) the
medical student in the operating room. Semantic
differential instruments were therefore devised to explore
these three conceptual areas.

The "Surgeon" semantic differential was intended to
explore differences among the three groups in their
attitudes toward surgeons following the treatment
administered to the two treatment groups. This research
question grew out of the notion that a self-selection
process of career interest and selection might be operating
in medical students in relation to surgery. Specifically,
it might be that medical students' experiences of unpleasant
physiological and emotional reactions to surgery might
influence them to conclude that they were not ”cut out” to
be surgeons. In addition, these reactions might subtly
promote a somewhat negative stereotype of the surgeon as a
cold, insensitive technician on the basis of a possible
belief that only such a person could be unaffected by the
stimuli experienced as noxious by the medical student. If
significant differences appeared on the State Anxiety
Inventory, the Operating Room Experience Inventory or the
Apprehension to Surgical Procedures Questionnaire, there-

fore, it might be predicted that similar differences

79

relating to a more positive or negative attitude toward
surgeons and surgery might also exist. The "Surgeon"
semantic differential was devised to explore this question.
"Surgeon," rather than "surgery,“ was chosen as the concept
to be rated by the medical students because it was felt that
the application of adjectives to the noun surgeon would be
more easily understood by the students than the application
of the chosen pairs of adjectives to the act of operating.
These concepts were quite obviously related, and Tannenbaum
(1966) showed that if the attitude of a group toward one
concept was changed, attitudes toward linked or related
concepts would be changed in the same direction. The
construction of the ”Surgeon” semantic differential began
with the circulation of ninety adjective pairs to Edward
Coppola, M.D., Professor of Surgery at M.S.U.; Norman Kagan,
EWnD., Professor of Counseling Psychology and of Psychiatry
at M.SJL; and Teresa Cochran, PhJL, Director of Surgical
Education at MMSJL The pairs of bipolar adjectives were
drawn from Osgood et al. (1957), a list that Coppola and
Cochran had devised, and some pairs added by the author.
Osgood's pairs included several which had shown loadings on
factors named evaluation, potency and activity in previous
research (Osgood et al., 1957). Coppola, Kagan and Cochran
were asked individually to choose twenty-five adjective
pairs which they thought met the following criteria:

(1) understandable by the medical student in the
project with the lowest vocabulary level

(2) relevant to the concept "surgeon" and to the

80
hypothesized difference among the three
groups, i.e., that the full-treatment group

would have a more positive concept of

surgeons
(3) likely to discriminate among students and

groups, i.e., that students would be apt to
score it differently, thereby increasing the
likelihood of finding differences if they
existed '

Based on these choices, a list of twenty-one adjective
pairs was compiled to be used in the ”Surgeon" semantic
differential. When each triplet completed this outcome
measure following their observation of an«operation, they
were reminded that they were to rate their concept of
surgeons in general, rather than the surgeon whom they had
just observed.

Two distinct semantic differentials were used to assess
medical students' attitudes toward themselves. One of these
assessed the student's attitude toward him/herself in
general and the other assessed the studentls attitude toward
him/herself during the time in the operating room. The
first of these two measures consisted of the same adjectival
pairs used in the "Surgeon" semantic differential and
attempted to assess both general self-perception differences
among the groups and similarities between students'
attitudes toward surgeons and attitudes toward themselves.
The second of these two "Self" semantic differentials, which
attempted to assess the student's attitude toward
him/herself during the time s/he was in the operating room,

was based on the hypothesis that even if significant

differences were not found in the anxiety and learning

81
measures, there might nonetheless be subtle differences in
self-perception while in the O.R. In order to develop a
good list of bipolar adjectives to explore this question, a
list of ninety adjectives was circulated to the three
counseling psychology doctoral students who were employed as
inquirers in the project as well as to J. Bruce Burke,
Ph.D., Professor in the College of Education at M.S.U.
These people were familiar both with the recall process and
with the content of the recalls of the medical students in
the project. It was felt that consultation with these
people would yield adjective pairs which might tap a subtle
yet real difference in self-perception while in the OgR.
among the three groups of students, a difference perhaps
influenced by the self-scrutiny and increased self-awareness
fostered by the IPR recall. The ninety-adjective list was
reduced to thirty-two and recirculated to the above persons,
yielding a final list of eleven adjectives. These
adjectives were paired with their opposites to create the
final measure. In each semantic differential, adjective

pairs were randomly reversed to avoid response bias.

Medical Specialty Questionnaire
The Medical Specialty Questionnaire was devised to
obtain information about the medical student's planned
specialty, degree of certainty about that specialty, and the
student's ranking of the relative attractiveness of eight

medical specialties. The primary piece of datum yielded by

82
this form was the ranking of the attractiveness of surgery

as a career specialty.

Impression Paragraph
The Impression Paragraph asked the medical student to
describe in twenty-five words or less what impressed him/her
about the operating room experience just completed.
Analysis of these paragraphs consisted of group comparisons
on three frequencies:
(1) a word frequency

(2) a frequency of the first-person personal pronouns
"I” and "Me"

(3) a frequency of the number of affective statements,
defined as phrases or clauses including one or
more affective terms

The word frequency yielded a global index of self-

expression in this specific situation (following observation
of an operation). The I-ME frequency yielded an index of
self-referenced expression. The affective statement
frequency, tabulated by two members of the NIMH research
team, provided an index of affective content. The alpha
reliability coefficient for the two affective statement
frequencies was .97. It was felt that one or more of these

frequencies might show a difference among the three groups

which might not display itself on any of the other measures.

83

Interim Observation Form

 

After completing the eight outcome measures, each
medical student completed an Interim Observation Form
(Appendix CH which obtained information regarding any
surgical experience the student may have gained outside the
project since the beginning of the project. This form
followed the format of the participation form used at the
beginning of the project. The "experience score" obtained
from the Interim Observation Form was added to the studentka
original experience score to yield a single experience score

to be used as a covariate in the data analysis.

Analysis

Although a two-way analysis of variance, crossing
treatment and experience, was originally planned, the use of
experience as an independent variable proved impossible due
to the realities of scheduling. It was therefore decided to
use experience as a covariate. Preliminary one-way analyses
of variance were performed for all eight outcome measures,
including analyses of the individual scales on the three
semantic differentials. Chi-square analyses were also done,
as well as two non-parametric tests, median and Kruskal-
Wallis one-way ANOVA, on the surgery ranking. If some
outcome measures had proven to be highly correlated (e.g.,
the semantic differentials) these would have been grouped
together in a multivariate analysis~ of variance.
Significant results were» not obtained, therefore

multivariate analysis was not required.

84

Hypotheses

 

Experimental
I. Ho:
H1:

II. H0:
H1:

III. Ho:
H1:

IV. Ho.
H1:

V. Ho:
HI:

VI. H0:
H1:

There will be no significant differences among
the three groups on the State Anxiety

Inventory.

Group one will score significantly lower on
the STAI than Groups Two and Three.

There will be no significant differences among
the three groups on the Operating Room
Experience Inventory.

Group one will score significantly higher on
the OJLE. inventory than Groups Two and

Three.

There will be no significant differences among
the three groups on the Apprehension to
Surgical Procedures Questionnaire.

Group one will score significantly lower on
the A.S.P.Q. than Groups Two and Three.

There will be no significant differences among
the three groups on the ”Surgeon,” "Self,” and

”Myself in the CLRW" semantic differential
scales.

Group one will score significantl higher,
i.e., rate the concepts more positively, on
the ”Surgeon," 'Selffl' and ”Myself ix: the
O.R.” semantic differential scales than Groups
Two and Three.

There will be no significant differences among
the three groups in their ranking of the
attractiveness of surgery as a career
specialty.

Group one will rank surgery significantly
higher in attractiveness as a career specialty
than Groups Two and Three.

There will be no significant differences among
the three groups in the word frequency, first-
person personal pronoun frequency, and
affective statement frequency in the
Impression Paragraph.

Group one will score significantly higher on
word frequency, first-person personal pronoun
frequency, and affective statement frequency
in the Impression Paragraph than Groups Two

85

and Three.

Delimitations

I.

II.

No measures of physiological responsiveness were
taken while the medical students were in the

operating room due to technological and space
limitations.

No attempt was made to follow this group of medical
students to determine which students did in fact
enter surgery as a career specialty.

CHAPTER IV
RESULTS

Introduction

 

The results of the data analysis are presented in the
same format as the categories of outcome measures outlined
in Chapter Three. The dependent variables, the instruments
used to measure them, and the hypotheses to which they

pertain are identified below:

 

 

 

Dependent Variables Outcome Measures Hypotheses

l. Emotional-Physiological STAI, ASPQ I, III
Reactivity

2. Learning (Observation) ORE II

3. Attitudes "Surgeon," "Myself IV

in the O.R.,” and

"Self" Semantic

Differentials

4. Surgery Ranking Medical Specialty V
Questionnaire

5. Impressions Impression VI

Paragraph'(word

frequency, I-ME frequency,
affective statement
frequency)

86

87
Appendix I contains copies of the measures.

Analysis of variance (ANOVA) was used as the primary
statistical analysis for each outcome measures ANOVA was
the appropriate statistical procedure because it allows
comparison of means of two or more groups. The conventional

.05 alpha level was used. One-tailed significance tests
were used because it was expected that results would lie in
the upper or lower half of the distribution, depending on
the outcome measure. The degrees of freedom for the ANOVAs
in this study were 2 between groups (number of groups minus
1) and 42 within groups (number of subjects minus number of
groups). One exception was the surgery specialty ranking, in
which two students did not rank all the specialty areas.
This resulted in 2 and 40 degrees of freedom respectively.

Chi-square analysis was used on the surgery ranking and
on each item of the three semantic differential scales.
Chi-square was appropriate because the scores on these
scales are categorical rather than continuous in nature:
chi-square relies upon categorical data. The chi-square
statistic has degrees of freedom equal to (rows minus 1)
(columns minus 1). This varied depending on the number of
categories checked by the students on the semantic
differential items.

Two non-parametric tests of significance, the Kruskal-
Wallisione—way'ANOVAxand the chi-square median test, were
used on the surgery ranking outcome measure. These tests

are better suited to rank-order data than are parametric

88
tests and Ch) not require assumptions of normality and
equality of variance (homoscedasticity).

The means and standard deviations for the various
measures are provided in Table 4-1, the ANOVAs are
summarized in Table 4-2, and the additional tests on the
surgery ranking are summarized in Table 4—3.

The remainder of this chapter contains sections on each
of the five dependent variables described earlier. Each
section includes a statement of the pertinent hypothesis-
(es), a description of the scoring of the measure(s), and a
statement of the results. The hypotheses are preceded by

the Roman numerals used in Chapter Three.

Emotional-Physiological Reactivity

Hypotheses

 

I. Group One will score significantly lower on the State
Anxiety Inventory (STAI) than Groups Two and Three.
ItL.Group One will score significantly lower on the

Apprehension to Surgical Procedures Questionnaire

(ASPQ) Checklist than Groups Two and Three.

Scoringyof Measures

 

The STAI consisted of twenty items of the following
type:

I felt calm . . .

I was tense . . .

Student responses on the STAI were scored, as stated in the

89

test manual (Spielberger et al., 1970), as follows: Not at
all = 1; Somewhat = 2; Moderately so = 3; and Very much so =
4. Scores in the study ranged from 23 to 54. A higher
score indicated a higher level of state anxiety (e.g., the
highest possible score of 80 would signify a very high state
anxiety level). To reduce response bias on the part of the
subjects, ten items are scored directly and ten are
reversed.

The ASPQ Checklist contained thirty-six stimulus items
of the following type:

incision

helplessness of patient
Students responded by indicating the degree to which they
were bothered by the various stimuli. Their responses were
scored: Didn't bother me = 0; Bothered me a little = l;
Bothered me a lot a 2; Does not apply = 0. The possible
range of scores was 0 to 72. Higher scores were associated

with higher levels of responsiveness to surgical stimuli.

Results
Means and standard deviations are presented for each
group in Table 4.1 and a summary of the ANOVAs in Table 4.2.

No significant differences were found.

90

Learning (Observation)

Hypothesis

 

II. Group One will score significantly higher on the Opera-
ting Room Experience (ORE) Inventory than Groups Two

and Three.

Scoring of Measure
A maximum score of 37.5 on the ORE indicated a very
high degree of accurate observation. Correct answers on
yes-no, multiple choice, and questions requiring a single-
number answer were awarded one point eachm‘The‘answers to
questions requiring short written answers earned from two to

six points based on the extent and accuracy of the response.

Results
The three groups did not differ significantly on the
Operating Room Experience Inventory. Means, standard
deviations and the ANOVA summary are presented in Tables 4.1

and 4.2.

Attitudes

 

Hypothesis

 

IV. Group One will score significantly higher, i.e., rate
the concepts more positively, on the "Surgeonfl'"Self,"
and "Myself in the OJL” semantic differentials than

Groups Two and Three.

91

Scoring of Measures

 

Students responded to sets of bipolar adjectives like
sensitive-insensitive and impulsive-thoughtful by indicating
how closely related they felt one or the other adjective was
to the concept being rated. The Surgeon and Self semantic
differential scales were scored as follows: Very closely
related (to the positive polar adjective) a 7: Quite closely
related a 6; Only slightly related = 5; Neutral or equally
associated = 4; Only slightly related (to the negative polar
adjective) = 3; Quite closely related a 2; Very closely
related = 1. On the "Myself in the O.R." scale, the middle
neutral category was eliminated and a forced-choice format
was used.

An average score was computed for each student on each
measure. Average scores were used rather than total scores
to compensate for items skipped. Possible range of scores
was 1 to 7 on the ”Surgeon” and "Self" measures and 1 to 6
on ”Myself in the O.R."I Higher scores indicated more
positive rating of the concept. Items on which the positive-
negative dimension was unclear or highly subjective were

deleted from the analysis.

Results
There were no significant differences among the three
groups on the "Surgeon," ”Myself in the O.R.," and "Self"
semantic differentials, either in average scores or in

individual item analysis. Students chose the same

92
adjectives to describe themselves and surgeons in all cases
but two. Students described surgeons as egotistic and
arrogant and themselves as correspondingly altruistic and
humble. Means and ANOVAs are presented in Tables 4.1 and

4.2, respectively.
Specialty Rankings

Hypothesis
V; Group One will rank surgery significantly higher in
attractiveness as a career specialty than Groups Two

and Three.

Scoring of Measure

 

Each student ranked the attractiveness of surgery as a
career specialty in a list of eight specialties. The
highest rank was 1; the lowest was 8. Two students, one in
Group Two and one in Group Three, did not rank all eight
specialties. Their scores were deleted from the final
analysis. In addition to analysis of variance and chi-
square analysis, two non-parametric tests were done on the
surgery ranking, a median test and a Kruskal-Wallis one-way

ANOVA.

Results
Although the surgery rankings of the three groups
were in the hypothesized direction, iJL, Group One ranked
surgery higher than Groups Two and Three, the analysis of

variance and the two non-parametric tests did not show

93
significant differences among the groups. The chi-square
analysis showed the differences to be significant at the .06
level. This result should be interpreted with caution,
however, because several of the chi-square cells had fewer
than five cases. Surgery ranking means and the ANOVA are
presented in Tables 4.1 and 4.2. The chi-square analysis
and the results of the non-parametric tests are presented in

Table 4.3.
Impressions

Hypothesis
VT. Group One will score significantly higher on word
frequency, first-person personal pronoun frequency, and
affective statement frequency in the Impression

Paragraph than Groups Two and Three.

Scoring of Measure

The word frequency and the I-ME frequency were simple
totals of the number of words and of first-person personal
pronouns. A frequency of affective statements was done by
each of two raters who were part of the research team.
Consensus was reached on the definition of ”affective
statement" as any phrase or clause containing one or more
affective terms. Analysis of variance was performed on

these frequencies.

94
Results
No significant differences were found among the three
groups on the word frequency, first-personal personal
pronoun frequency, or affective statement frequency. Means
and ANOVAs are presented in Tables 4.1 and 4.2,

respectively.

95

Table 4.1. Means and Standard Deviations

 

 

Outcome Measure Mean Standard N
Deviation

1. State Anxiety Inventory

(STAI)

Group One 32.40 5.59 15

Group Two 31.07 4.30 15

Group Three 35.07 8.15 15
2. Apprenhension to Surgical

Procedures

Questionnaire (ASPQ)

Checklist

Group One 3.87 4.45 15

Group Two 3.53 2.39 15

Group Three 4.53 4.31 15
3. Operating Room

Experience Inventory

(ORE)

Group One 27.80 4.11 15

Group Two 27.93 3.83 15

Group Three 29.40 2.75 15
4. ”Surgeon" Semantic

Differential

Group One 3.18 .86 15

Group Two 2.97 .77 15

Group Three 3.25 .95 15
5. "Myself in the O.R.”

Semantic Differential

Group One 2.19 .53 15

Group Two 1.99 .42 15

Group Three 2.16 .55 15
6. "Self" Semantic

Differential

Group One 2.63 .45 15

Group Two 2.32 .50 15

Group Three 2.26 .73 15
7. Medical Specialty

Questionnaire

(Surgery Ranking)

Group One 3.73 1.53 15

Group Two 3.93 2.23 14

Group Three 4.71 2.16 14

96

Table 4.1. Means and Standard Deviations (cont'd)

 

Outcome Measure Mean Standard
Deviation

 

8. Impression Paragraph:
Word Frequency:

Group One 33.33 25.26

Group Two 31.00 18.17

Group Three 28.00 16.77
I-ME Frequency:

Group One 1.20 1.74

Group Two 1.67 2.23

Group Three 1.13 ‘1.51
Affective Statement Frequency:

Rater One

Group One 1.13 1.25

Group Two 1.07 1.33

Group Three .87 1.13
Rater Two

Group One .93 1.33

Group Two .80 1.08

Group Three .80 1.21

15

15
15

15
15
15

15
15
15

15
15
15

97

Table 4.2. Summary of Analysis of Variance

 

Outcome Sum of Degrees Mean F
Measures Squares of Freedom Square Ratio

 

1. State Anxiety Inventory

(STAI)
Between 124.44 2 62.22 1.61
Within 1627.27 42 38.75

2. Apprehension to Surgical
Procedures Questionnaire
(ASPQ) Checklist
Between 7.78 2 3.89 .26
Within 617.20 42 14.70

3. Operating Room Experience
Inventory (ORE)

Between 23.64 2 11.82 .91
Within 546.93 42 13.02
4. "Surgeon" Semantic
Differential
Between .63 2 .31 .42
Within 31.25 42 .74

5. ”Myself in the O.R."
Semantic Differential

Between .32 2 .16 .64
Within 10.67 42 .25
6. ”Self" Semantic
Differential
Between 1.20 2 .60 1.85
Within 13.65 42 .32
7. Medical Specialty
Questionnaire
(Surgery Ranking)
Between 7.70 2 3.85 .97
Within 158.72 40 3.97

8. Impression Paragraph:
Word Frequency:
Between 214.44 2 107.22 .26
Within 17493.33 42 416.51

I-ME Frequency:
Between 2.53 2 1.27 .37
Within 143.47 42 3.42

98

Table 4.2. Summary of Analysis of Variance (cont'd)

 

Outcome Sum of Degrees Mean F
Measures Squares of Freedom Square Ratio

 

Affective Statement Frequency:
Rater One
Between .58 2 .29 .83
Within 64.40 42 1.53

Rater Two
Between .18 2 .09 .94
Within 61.73 42 1.47

 

99

Table 4.3. Tests on Surgery Ranking

 

 

Test of Chi- Degrees of P
Significance Square Freedom Value
Chi-square 22.96 14 .06
Kruskal-Wallis

One-Way ANOVA 1.48 2 .48
Median Test 2.79 2 .25

 

CHAPTER V

SUMMARY, CONCLUSIONS, DISCUSSION AND IMPLICATIONS

Summary

This investigation was an attempt to evaluate the
effectiveness of a three-phase treatment based on the IPR
nmdel in increasing the learning and decreasing the
emotional-physiological reactivity of medical students in
their early surgical training. The study also sought to
assess the effect of the treatment on medical student
attitudes toward surgery and themselves and on students'
career preferences.

The present study grew from Embelton's (1981) study and
earlier work of Coppola, Cochran and Kagan. Coppola and
Cochran (1979) surveyed medical students in their surgical
clerkships and found that about one—third of the students
reported unpleasant emotional-physiological reactions to
common surgical stimuli. Kagan's IPR method had been used
successfully to improve the patient interviewing skills of
medical students (Werner & Schneider, 1974L. Coppola and
Cochran suggested to Kagan that the IPR method be adapted to
assist students in their early surgical learning by reducing
their responsiveness to noxious surgical stimuli. This

collaboration among the three led to the Embelton (1981)

100

101

study which used a matched-pairs design to investigate the
effects of a two-session IPR laboratory treatment on medical
students' learning (observation) and anxiety in an early
surgical experience. ‘Embelton's study, conducted in the
summer of 1979, found no significant differences between his
groups, one of which received the two-session IPR laboratory
treatment in which students viewed videotaped vignettes of
actual surgical and simulated interpersonal events and the
other of which received notreatment. A 1980 survey by
Coppola and Cochran confirmed the incidence of negative
reactions in clerkship students to early surgical experi-
ences. Embelton (1981) discussed the possibility that the
treatment had increased anxiety toward surgery and that this
had masked any positive effects the treatment may have had.
In addition, the treatment time was less than that given in
IPR studies which had found significant results. Embelton
offered several suggestions for strengthening the treatment
and outcome measures which were incorporated into the
present study.

The present study conceptualized the problem of the
possible impact of adverse reactions to surgery on medical
students' learning and anxiety in information processing
terms. The information processing model was used as a
theoretical base. The literature on the relationship between
emotion and learning was reviewed, especially as it pertains
to the processes posited by information processing theory.

The influence of expectancy (Tolman, 1938; Bandura, 1977)

102
and of appraisal and reappraisal of threat on attention and
retention processes and on emotional experience and
expression has been shown by Arnold (1950),:Lazarus (1966,
1968), and Bandura (1977). Bower (1981) and Weingartner et
an" (1977) confirmed the influence of mood on the crucial
learning process of memory.

The literature confirmed the Yerkes-Dodson Law, which
emphasized the close relationship between attention and
arousal and states that "with increases in arousal,
performance on any task increases up to some point, beyond
which further arousal leads to a decrease in performance"
(Reynolds & Flagg, 1977, p. 27). On more difficult tasks,
performance peaked earlier, a curvilinear relationship which
Easterbrook (1959) explained in cue utilization terms. The
important elements in the Easterbrook hypothesis were range
and relevancy of cues utilized. Increases in arousal are
associated with increasing selectivity of cues. Performance
improves as irrelevant cues are ignored, depending upon the
importance of ”incidental learning” (Dusek, et al., 1975,
1976L. Increases in arousal at some point cause relevant
cues to be ignored, and performance deteriorates. Sarason
(1972) and Wine (1971) suggested that more anxious students
divide their attention between the demands of the task and
preoccupation with somatic concerns and negative self-
references. Less anxious students generally devote more of
their attention to task demands and less concern to task-

irrelevant issues. The greater the interference at this

103
point, the smaller the amount of instructional content
available to be processed.

Spielberger, et al.(1970) Operationalized his state-
trait conceptualization of anxiety in the two forms of the
State-Trait Anxiety Inventory, the State form of which was
employed in the current study. Further explication of the
multidimensionality of the concept of anxiety has been done
by Deffenbacher (1980) and Endler (1980).

The literature on the importance of the clerkship,
especially the surgical clerkship, in medical students'
career choice generally confirmed the solidification of
career choice through the course of medical school and the
clerkships. Hutchins (1964) and Chapman (1976) reported
that about one-third of students tend to change their minds
one or more times during clerkships. Although this seemed
to emphasize the importance of clerkships in career choice,
students choosing surgery as a specialty generally made a
firmer choice earlier than do other students (Wasserman, et
al., 1969: Michigan Study, 1978).

Medical students' attitudes toward surgeons and surgery
were clear and consistent. Surgery was consistently ranked
very high in status and very low in social attractiveness to
medical students (Zimet & Held, 1975; McGrath & Zimet,
1977). Bruhn and Parsons (1964) found that medical students
viewed surgeons as "domineering, arrogant, and aggressive”
(p. 43).

The treatment evaluated in the present study was based

104
on the IPR mode1.(Kagan, 1979L. The treatment goal was to
increase students' awareness of their adverse reactions and
explore positive ways of coping with these reactions.

A three-group posttest-only control group’design was
used. Group One students (n=15) were given two sessions in
the IPR lab in which they were videotaped while viewing a
series of color videotaped stimulus vignettes of actual
surgical and simulated interpersonal events (e.g., various
operations, a surgeon saying ”Hold still, goddammit, I
can't see what I'm doing."). Heart rate, skin conductance
and respiration were monitored while the student viewed the
vignettes. These records were shown to the student while
the student viewed the videotape of him/herself and recalled
his/her responses to the vignettes. The responses were
discussed with an inquirer wholencouraged exploration but
left control of the discussion with the student. Group One
students also viewed an instructional videotape offering
methods of coping with adverse reactions. Students were
then videotaped while watching an operation and reviewed the
videotape to discuss their reactions to this experience with
an inquirer. Group Two students (n=15) watched one opera-
tion prior to the outcome phase of the study, and Group
Three (n=15) was a control group. Finally, student
"triplets," consisting of one student from each group,
observed an operation and responded to eight paper and
pencil instruments intended tn) measure emotional-

physiological reactivity, learning (observation), attitudes,

105

career preference, and impressions of this early O.R.
experience. It was hypothesized that Group One would report
less reactivity, be more observant and more positive in
attitude toward themselves and surgeons, rank surgery more
highLy as a career preference, and have more positive
impressions about the OJL experience than the other two
groups.

Analysis of variance and chi-square test of
association, as well as two non-parametric tests on the
surgery ranking, showed no significant differences among the
three groups on the dependent variables. The chi-square
test on the surgery ranking did show the three groups to
differ in the hypothesized direction (i.e. Group One ranked
surgery the highest of the three groups) at the .06 level of
significance, but this result should be interpreted with
caution, because several of the chi-square cells had fewer

than five cases.

Conclusions

 

I.There were no significant differences among the three
groups on the State Anxiety Inventory (STAI).

II. There were no significant differences among the three
groups on the Operating Room Experience (ORE)
Inventory.

III. There were no significant differences among the three
groups on the Apprehension to Surgical Procedures

Questionnaire (ASPQ). The results of the ASPQ revealed that

106
the medical students rated the following seven surgical
stimuli as the most bothersome of the thirty-six ASPQ
stimuli: helplessness of the patient, mutilation, incision,
wearing mask, intubation, retracting, and cauterization.
These results were similar to those of Embelton (1981).

IV. There were no significant differences among the three
groups on the "Surgeon," "Self,” and "Myself in the
OJL” semantic differentials. Of the three semantic
differential instruments employed in the study, the
"Surgeon" and "Self" inventories yielded the most
interesting results. The students' scores on the
individual items of these two identical lists of polar
adjectives added qualified confirmation to the findings
of earlier investigators. Although students in the
present study described themselves and surgeons more
similarly than did students in other studies, the
different adjectives which students ascribed to
surgeons (egotistic and arrogant) as opposed to
themselves (altruistic and humble) supported the notion
of the negative surgeon stereotype.

V. ANOVA and two non-parametric tests of group rankings of
surgery as a career specialty showed no significant
differences among the groups, although Group»One did
rank surgery higher than the other two groups. A chi-
square test of association revealed a difference among
the groups significant at the .06 level, but as already

mentioned this result should be interpreted cautiously

107
because there were fewer than five cases in several of

the chi-square cells.

VI. There were no significant differences among the three
groups on the word count, first-person personal pronoun
count, and affective statement count in the Impression

Paragraph.

Discussion

 

The most obvious conclusion from the data analysis was
that the treatment did not make a difference. This section
focuses on four general areas of the study in an attempt to
interpret the lack of significant results. The areas are:

sample, theory, treatment, and instrumentation.

Sample

There was considerable experimental mortality'in the
study (26%). Although the final sample size of 45 medical
students did not yield results as firm as a larger sample
could have, the sample size was adequate to perform the
planned analyses. There was little differential mortality
from the three groups, but more males (93%) than females
(28%) and more osteopathic (79%) than allopathic (65%)
students completed the study (Table 3.1). In addition to
limiting the generalizability of the results, these figures
shed light on some issues central to the studyu The much
higher attrition rate of females may relate to factors such
as the mostly-male composition of the research team and of

surgical specialties generally, but it may also relate to

108

the issue of adverse reactions to surgical stimuli. Given
that scheduling was a difficulty, especially in the outcome
phase of the study, why did such a lower percentage of women
students complete the study than men? Traditional sex
role stereotypes may have interacted with the fact of male
domination of surgery. Although the number of women
surgeons in the United States doubled from 1970 to 1978,
women still comprised less than four percent of the total
number of surgeons in the country (American College of
Surgeons, 1980). Did some of the female students see less
'reason to seek (additional) early exposureeto surgery than
did their male counterparts because the females saw
themselves as largely excluded from a surgical career? Or
were the female students more sensitive to surgical scenes?
Such speculations may explain the female students being less
enthusiastic about the study, less flexible in their time
schedules, and therefore more likely to not complete the
study. Still, explanations of this phenomenon remain in the
domain of conjecture.

The differential participation of College of
Osteopathic Medicine (COM) and College of Human Medicine
(CHM) students seemed to relate primarily to opportunities
for exposure to surgery, which were much greater for CHM
students than for COM students. CHM students had a required
surgical clerkship as part of their training and COM

students did not. Presently, the vast majority of surgeons

109
are allopathic physicians.

It is possible that women students and allopathic
students may differ from men and osteopathic students,
respectively, in their reactions to surgery due to some of
the surgical education issues cited above. If so, a
treatment administered to a more representative sample might
have been successful in producing intergroup differences.
All the students who participated seemed to value the
opportunity provided by the study for exposure to surgery,

but this was especially true for the osteopathic students.

Theory

The literature on arousal, cue utilization and
incidental learning was especially relevant in explaining
the lack of significant findings in the study. Easterbrook
(1959) hypothesized that as arousal increased, the range of
cue use was reduced. Dusek et al. (1975; 1976) found,
however, that lower anxiety was associated with better
learning on a central task but poorer incidental learning.
As Embelton (1981) speculated, it may be that the treatment
increased arousal to the point of reducing the range of cue
use. Previous IPR studies had found significant differences
between treatment and control groups, but usually in
training programs of twenty to fifty hours (Dendy, 1971;
Kingdon, 1975). But if the treatment did not make a
positive difference, neither did it have a negative impact,

which would have added support to EmbeltonWs"oversensitiza-

110

tion" hypothesis, which states that the treatment may have
increased anxiety. Another possible explanation of these
results was that the outcome measures were flawed in such a
way that Group One was less anxious than the other groups
and was therefore somewhat less observant of incidental
stimuli. Therefore, to the extent that the Operating Room
Experience (ORE) inventory measures incidental learning, one
could have expected Group One to score lower than the other
two groups on this measure if Group One students were in
fact less anxious.

The nature of medical student reactivity to surgery and
the effects of this reactivity on early surgical learning,
attitudes and career preference are complex. .A major
element of this complexity probably lies in the idiosyncracy
of this reactivity and its effects, in short, in individual
psychology. In addition, the surgeon must confront and deal
with crucial situations unlike those normally encountered by
others. Selzer (1979) testifies eloquently tn: the
idiosyncracy of this rare interaction of individual and
situation, the act of surgery:

Forty years ago my father was a general practi-

tioner in Troy, New York. That was before the age

of specialization in medicine, and family doctors

did just about everything-delivered babies, set

broken legs, and removed ruptured appendixes.

Despite this last, I do not think of him as a

surgeon. I never watched him standing at an

operating table, making an incision. But I did

see him every Sunday, kneeling in his garden which

he treated as though it were a ward full of

patients. All day long he spent there, pruning,

excavating weeds or splinting a slender stalk and
marveling aloud at the exuberant swelling that

111

bloomed at its tip. Now I am the age that he was.
Then we are the same age! And now I can see what

I must have seen years ago but had forgotten-his
hairless white wrists submerged among the carna-

tions, as though gripped by the lips of an
incision. I do not see his fingers, hidden as
they were in the foliage, busy down below,
repairing the work. But I remember the air carved
by bees, and the slow respiration of the trees.
Sometimes, even now, in my operating room, as I
clamp, ligate, and suture, I know a deeper kinship
with my father. Something arcs across the
decades, like a rainbow that binds the earth as if
it were gift. Why just today a red flower bloomed
at the end of my scalpel: a poppy, I think. It

seemed a miracle, like the leafing out of a
shepherd's crook. I pinched off the bloom and

tied down the stem with thread. My father was

right. Surgery is gardening (p. 109).
Endler's (1980) proposal of a person-situation interaction
model of anxiety holds promise for future exploration of
specific interactions like that of the medical student in
early surgical training. Building on the state-trait theory
of Spielberger et al.(1970), Endler identified cognitive-
worry (such as negative self-evaluations) and emotional
arousal components in state—anxiety, and social evaluation,
interpersonal ego threat and physical danger dimensions of
trait-anxiety. Some of these dimensions, eLg., social
evaluation and interpersonal ego threat, may have bearing on
medical students'early surgical training. This model is
referred to again in the instrumentation section in this

chapter.

112

Treatment

 

As stated in the previous section, it is possible that
the amount of treatment time "was insufficient to effect
such basic and aversive reactions to surgical stimuli and
the whole nature of surgery, which is viewed as an
aggressive act ”(Embelton, 1981; p. 88). The addition of
the instructional component and of the hospital recall was
intended to strengthen the treatment, but the results did
not confirm this. The instructional videotape was a
shortened version of a videotape which previous groups of
students had reported as helpful in their adjustment to the
surgical clerkship. lThe fact that the excerpt dealt only
with coping with adverse reactions in the operating room and
that it was viewed by the students at the end of the second
laboratory session, when the effects of the vignettes were
very fresh, may have lessened its positive effect on
students' confidence in their ability to cope with their
reactions. The IPR recall of the Group One students in
their first surgical experience in the study was intended to
strengthen the laboratory treatment by in vivo exposure.
Based on the author's observations through the course of the
study, the videotaping of the medical student in his/her
first surgical experience in the study introduced another
element in the situation, possibly altering the situation
enough to affect the student's experience of it. Most
students showed interest in the surgical procedures observed

and recalled this interest and curiosity in the recalls.

113

They generally seemed less concerned with, aware of, and/or
willing to discuss with the inquirer any adverse reactions
they may have experienced. This may have been due partly to
the students' greater interest in the opportunity to observe
an operation than in processing his/her reactions to it with
the inquirer. Individual styles of learning, coping and
defense may well be important variables influencing the
relative impact of the IPR method on medical students.
Perhaps videotaping and doing recalls with students on their
second or third O.R. observation would have been more
beneficial.

Creation of life-like vignettes was a problem in the
current study, as it had been in Embelton's (1981) study.
Operating room lights made true color reproduction very
difficult. Some students commented on this, as well as on
the acting ability'of some of the actors in the vignettes.
The actual surgery vignettes used in the present study were
generally longer than those used by Embelton, which allowed
students sufficient time to orient themselves to the
particular anatomy involved in the surgery. Students
generally showed interest and curiosity toward the vignettes
similar to that which they displayed in the hospital recall
treatment experience, but were perhaps more relaxed during
the vignette recalls than the hospital recalls, assuming
that greater tension is associated with an actual operating

room experience than with a laboratory experience.

114

Instrumentation

 

The State Anxiety Inventory (Spielberger, et al., 1970)
was the only standardized measure used in the study.
Although this measure had generally good reliability, it may
have missed dimensions of anxiety discussed by Endler
(1980). In referring to three of the dimensions of person-
situation interaction anxiety, Endler stated that:

In order for the person-by-situation (trait-by-

situational stress) interaction to be effective in

inducing A-State, it is necessary for the A-Trait
measure to be congruent to the threatening situa-
tion. For example, . . . interpersonal ego threat

A-Trait will interact with an interpersonally ego-
threatening situation to elicit A-State changes,

but will not interact with physical danger A-Trait

or with an ambiguous threat situation (p. 263).

Current work by Endler and others may produce an instrument
which may be more successful than the STAI in assessing, for
example, interpersonal.ego threat possibly experienced by
medical students in their early surgical training.

It is conceivable that better scores on the Operating
Room Experience (ORE) inventory may not be indicative of
better learning due to a decrease in interference of
emotional-physiological reactions. The ORE attempted to
measure observation in the operating room and was composed
largely of questions about the presence, number, and
descriptions of objects and events in the 02R. To the
extent that the ORE focused on attention to incidental
stimuli, the findings of Dusek, et a1. (1975, 1976) predict

that less anxious students would score lower on this measure

115
than more anxious students. It is possible that the ORE
failed to measure some more central yet subtle learning
which occurs in the O.R.

The Surgery Ranking was the only measure which
approached significance in this study, although the result
requires cautious interpretation. It cannot be interpreted
that the treatment increased the number of students who
prefer surgery as a career specialty, but the surgery
ranking result may imply a more positive attitude toward
surgery on the part of Group One students.

The Impression Paragraph was a highly exploratory
measure and was employed on the chance that it might tap a
difference among the groups which might not show on any of
the other measures. The measures of global, self-
referenced, and affective expression revealed no differences

among the groups.

Implications

The level of student interest and participation in the
study attested to students' enthusiasm and desire for early
exposure to surgery in the course of their medical training.
This was especially true for male students and for osteo-
pathic students. Some students had frequent opportunities
to observe operations prior to their surgical clerkships,
but many students felt apprehensive about early surgical
experiences. Informal ways of increasing pre-clerkship
opportunities for medical students to observe surgical

procedures would be welcomed by many students.

116

Some students might be assisted in coping with their
adverse reactions to surgery by a treatment program like
that used in the present study; but the unique learning,
coping, and defense style which the student brings to the
surgery situation must be better understood and considered
in attempting, for example, to predict which students will
find this type of experience helpful to them. As Tobias
(1979) pointed out, all treatment approaches may not equally
benefit all individuals. The IPR treatment experience no
doubt had different effects on different students. Future
research could explore this differential effect by investi-
gating the relationship between level of disclosure during
recall, for example, and various personality, motivational
strength and content, and information-processing style
variables.

The relative crudeness of the instrumentation in the
present study may have masked treatment effects. Embelton's
results and the results of this study do not necessarily
mean that the treatment approach was ineffective. A prime
area of interest in this regard was that of self and
interpersonal awareness. The treatment sought to increase
medical students' awareness of themselves and others, but
such differences may be very subtle and not subject to easy
measurement. A new research instrument which explores
medical student awareness as it relates to surgery and
surgical procedures more fully than did the measures

employed in this study might uncover a treatment effect not

117
found by the present measures.

Given the complexity of the phenomenon under investiga-
tion in this study, perhaps too much was expected of the
treatment, especially in regard to the attitudinal and
surgery preference measures. Attitudes are frequently quite
robust, as are surgery preferences relative to preferences
for other specialties. Perhaps an expectation of measurable
change in these areas after a treatment of a few hours is
unrealistic.

This study represented a unique collaboration in the
field of medical psychology and was highly exploratory in
nature. Further research in this area should focus on
examination of individual cases of medical students who
experience adverse reactions to surgery and are motivated to
explore these reactions in depth. Such ethnographic study
might contribute significantly to understanding the nature
and effects of these reactions and to develOpment of new
approaches to ameliorate them. The methods of ethnographic
study match more closely the requirements for investigating
such idiosyncratic phenomena as medical students'

introduction to the operating room and to surgery.

APPENDIX A

INVITATION TO PARTICIPATE

FIRST AND SECOND YEAR STUDENTS IN CHM AND COM

Edward D. Coppola, M.D. and Norman Kagan, Ph.D.

In the hope of improving the surgical experience for medical students, we intend

to offer again this year, over the summer period, a unique and exciting opportunity
for students to prepare for their surgical clerkships or preceptorships. Although
these procedures are experimental, the students who participated last year had very
positive reactions to the experience. Basically this preparatory learning experience
will require the following time commitment sometime between June 16 and August 22:

A. Two sessions of about two hours each of viewing surgical films and then re-
viewing and recalling a videotape of your reactions to the films. Ongoing
physiological responses will be monitored.
and/or

B. Two sessions of about three hours each of actual surgical experience in an op-
erating room.

In addition, four short questionnaires will be given.

If you are interested in participating, please complete the attached page and return
by May 22 to:

 

Edward D.Coppola, M.D.
8421 Clinical Center
Department of Surgery
Michigan State University

Phone: 353-5450

118 - —

T0: Medical Students ‘19

FROM: Russ Hogan, Coordinator of 1980
Summer Pre-Surgery Education Project

Date: June 5, 1980

23
ff]

Third time around!

If you have already returned the participation form for the 1980 Summer
Pre-Surgery Education Project sponsored by Dr. Coppola and Dr. Kagan, please
disregard this note.

For those of you who did not return the participation form. I wanted to
le~t you know that we are egpeciallv interested in students who have had little
(N‘no surgical experience. So if you have observed or assisted at no operations
or veryf ew and are interested in getting some experience, please complete and
return the form if you still have it, pick up a new form in B- 414 Clinical Center,
or call Maggie at 353-5450 in the daytime, or me at 351-2216 at night.

If you have already sent in the form or plan to, we will be contacting you

.5 I
RE)? 1723‘,

APPENDIX B

PARTICIPATION FORM

Pre-Surgery Education Project

(Please Print)

A.
8.

NAME AGE: MALE/FEMALE
ADDRESS:

ZIP CODE:

PHONE # :

PLEASE CIRCLE YEAR AND PROGRAM
FIRST YEAR SECOND YEAR CHM COM

PREVIOUS HOSPITAL AND MEDICAL EXPERIENCE:

0‘ 01 ch “NH
. . . . .

Self,as patient in surgery

Assistant in childbirth

Had close relative of immediate family involved

in a significant period of hospitalization

One or both parents are medical practitioners
(father/mother; specialty(ies)

Assisted in helping patients in hospital after

surgical operation

Number of surgical procedures (from minor, e.g. suturing,
to major, e.g. abdominal surgery) observed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

. O 1 2-3 4-6 7-11 12-20 20+
Emergency Room 2 .5 10 18 32 AG
Operating Room 1!» lo 20 36 611 PL
Physician's Office I 2 .j K j 16 2E

Number in which you assisted (scrubbed in and participated):
"""“' O 1 2-3 4-6 7-11 12-20 20+
ER D 10 20 36 5a A96
0R 6 15* 30 :u 96 155
Physician's Office 2* 57— 10 .1c 32 MB

 

 

 

 

Other previous clinical medical or surgical
experience - please describe:

MY BEST TIMES DAILY (8:00 a.m. - 8:00 p.m.) BETWEEN JUNE 16 AND AUGUST 22 ARE:

(Specify times) SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

RETURN TO: EDWARD D. COPPOLA, M.0.

B421 Clinical Center
Department of Surgery
Michigan State University

BY MAY 22
120

 

APPENDIX C

INQUIRER PROCEDURES

1980 Surgery Project

INQUIRER PROCEDURES

 

Especially for COM, less for CHM:

A. Describe Procedures

mm-fiwN—I
O O O C O O

Hook-up

Watch vignettes

Let him/her get involved with vignettes as much as possible
Videotaping

Split screen

Recall- thoughts, feelings, images, impressions, physical reactions

3. At Beginning of Recall, Explain Recall Process

Ulth-d

C. D

1.

Briefly explain physio

Student has control

Encourage to stop after each vignette
Talk about reactions

Taping

uring Recall
Usual inquiry leads

 

 

2. Surgery project leads
3. Focus on affective (especially anxiety, fear and physical manifestations)
ggg_cognitive (cues to type of operation, thoughts, etc.)
4. Use inquiry to help person label thoughts and feelings
5 Neither too deep to be appropriate nor too shallow to be meaningful -
if not sure, ask student
6. Open-ended, exploratory, sensitive
INQUIRER LEADS
Lab and O.R.R.
How might you have responded to that situation?

What
when

What
that

What
What

What
that

What
at th

do you think you could do about that reaction (e.g., feeling nauseated)
it occurs?

did you experience physiologically when that occurred? (When you had
feeling?) (Anything in muscles, stomach, throat?)

kind of operation did you think it was?
cues made you think that?

did you think/feel about the patient/surgeon/anesthesiologist/nurse at
point?

did you think the surgeon/anesthesiologist/nurse was thinking (feeling)
at DOIDI? 121

APPENDIX D

TYPESCRIPTS OF VIGNETTES

10.

11.

12.

1980 SurgicalIVignettes
Tape One

Introduction by R. E. Hogan

Patient on a cart: ”How long will the operation take,
doctor? When can I know the results?"

Operation: Prepping, draping, incision, and dissection
of a right carotidendarterectomy.

Operation: Intubation of an exploratory laparotomy
with excision of abdominal mass.

Operation: Local anaesthetic preparation for
intubation.

Operation: Incision through steridrape, electro-
cauterizing hemostasis, and dissection through
abdominal wall of appendectomy of a 6 y.o. male.

Operation: Incision and clamping of bleeders (of
probable ? cholecystectomy ?)

Surgeon: "Well now, what do you think this is? Oh
come on now, you can take a guess u. The pancreas?
You think this is the pancreas? (laughter) "

Operation: Chest retractors in place. Heart and aorta
in view. Resection of dissecting aneurysm of the
thoracic aorta in progress.

Surgical Scrub: "This time, sweety, don't put your
hands below the table and contaminate yourself."

Operation: Split-thickness skin graft taken from right
upper thigh of burned patient.

Operation: Suturing right inguinal incision of an
embolectomy of a 77ymo. female under local anesthesia.
Surgeon talks to patient. Undraping of the patient and
dressing of the wound.

Circulating Nurse: "That surgeon is a son-of—a-bitch.
He treats you like shit - the way he snaps orders. I
hate his guts. Wouldn't you agree?"

10.
11.

123

1980 Surgical Vignettes
Tape Two

Surgeon: "Well folks are we ready? Oh, you're the
student. Do you think you're up to this?"

Patient: Crying baby.

Operation: Ankle incision.

Operation: Hand debridement.

Surgeon: "He died before we could begin to operate.
I'd like you to go with me to tell the family."

Operation: Hip reconstruction.

Circulating Nurse: "Now you've contaminated yourself.
Don't touch anything. Stand there and don't move.
Don't they teach you medical students anything?”

Operation: Facial incision.

Surgeon: ”Will you hold still? I can't see what I'm
doing. God damn it."

Operation: Hernia.

Patient: Baby.

APPENDIX E

TRANSCRIPT OF INSTRUCTIONAL COMPONENT

Excerpted from: Learning on the Surgical Clerkship --
In the O.R. (Doran, Cochran, English, Alexander, 1979).

Before going into the OR, you should know what to do in case
you start to feel ill.

We have found that 30% of medical students experience this
common problem.

The reactions you should be aware of are:

a. a sensation of warmth, particularly facial

b. mild nausea or queasiness

c. excessive perspiration

CL A sensation that something is wrong, but you
are not clear, not sure whatfis wrong.

What should you do?
To cope with a mild physiological reaction, you could try:

a. lowering your head or looking away from the
surgical field

b. thinking of something else

c. concentrating on the more objective aspects of
the situation or

d. stepping back from the table for a few minutes

If these suggestions do not help and you feel as if you
might faint or vomit, then you should leave the operating
room promptly with the understanding that you may return,
and then,

sit down and wait until you feel better.

Or
drink some water or have a light snack.

Many students feel embarrased about leaving the OR. If you
have to leave the OR and return, that doesn't mean you are

unqualified or unprepared.

Remember that leaving is a positive, responsible approach to
solving a natural reaction to surgical procedures.

124

APPENDIX F

LETTER TO SURGEONS

 

.‘At

MICHIGAN STAT 1i UNIVERSITY

 

1.1:~r-\R1\11:,‘;1'm sum: in - 1m: (tuxutu H-‘xi'ra 159.51 LAxuxg . nun...“ . m”

.s;',1<13‘30
May 23, 1980

This note is to introduce Mr. Russ Hogan, a graduate student in edu-
cational psychology, who this summer will be doing the field work for his
doctoral dissertation under my supervision.

The project is a continuation of the Pre-Surgery Education Project
begun last sunrer in which you may have participated.

We have found that about 1/3 of all medical students have serious
adverse physiological and psychological responses to the environment and
activities in the operating rooms. These reactions and experiences may
not only impair student learning in the OR, but also may turn bright and
gifted students away from considering surgery as a career.

In order to find out more about this, a controlled experiment with
improved design will be done in June, July, and August. One group of
students will have a form of "combat training” before going to watch a
surgical procedure of magnitude, another group will not. The training
will be done in two stages using videotaped material, polygraph recordings,
and recall sessions in a laboratory environment.

We need the help of surgeons who would like to participate ty letting
"trained" and ”untrained" students watch their operations for purposes of
evaluation of the training.

Mr. Hogan will be glad to provide further details and respond to any
questions you might have. I'd greatly appreciate your willingness to par-
ticipate in this unique work in surigcal education by assisting Mr. Hogan.
Sincerely,

522.24% rip/M4—

Edward D. Coppola, M.
Professor of Surgery

1‘ f‘ .- -
CDC/1:15

.125

APPENDIX G

INFORMED CONSENT FORM

3/11/80

PRESURGERY EDUCATION PROJECT
INFORMED CONSENT FORM

Videotapes of your operation will be used in the education of medical

students fbr surgery.

I have freely consented to take part in an educational study being
conducted by Edward D. Coppola, M.D., Professor of Surgery, Michigan
State University at Ingham Medical Center and Sparrow Hospital.

.* I understand that I am free to discontinue my participation in the

study at any time without penalty.

I understand that the results of the study will be treated in strict
confidence and that I will not be identified by name.

I understand any of my inquiries regarding the research project will
be answered.

I understand that my participation in the study does not guarantee
any beneficial results to me.

 

 

 

Patient Signature Date
Surgeon Signature Date
Witness Signature Date

126

APPENDIX H

INSTRUCTION SHEET

.-.;
.m-

,-_
.-
¥

3

v

To

.4.

 

 

 

O.R. OBSERVATION AND QUESTIONNAIRES

For this phase of the Pre-surgery Education Project, you will observe an
operation for 1-1% hours with 2 other medical students. After you observe the oper-
ation” you will change out of your scrubs and go to another room to respond to
some questionnaires. The questionnaires will take about 35 minutes and relate to:

1) your observations in the O.R.
2) your reactions to the O.R. experience
3) some of your attitudes about surgery

It is important that your O.R. observations and reactions be independent of

 

those of your 2 fellow observers, so we ask that you

1) not discuss your activities i3 the Project

 

 

and

2) not discuss your observations or reactions before,

 

 

during 2£_after the operation. This i§_especially

 

 

important while you are i2_the O.R.

 

We want you to have equal chances to observe the procedure, so if you must
take turns occupying the best position for observing, please do so. Remember that
we are guests in the O.R., so please be considerate of the surgeon and other O.R.
personnel. If you need to leave the O.R. for any reason during the operation, you

may return later.

APPENDIX I

OUTCOME MEASURES

SELF-EVALUATION QUESTIONNAIRE

Developed by C. D. Spielberger, R. L. Gorsuch and R. Lushene

STAI FORM X-1
NUMBER DATE

 

DIRECTIONS: A number of statements which people have
used to describe themselves are given below. Read each state-
ment and then blacken in the appropriate circle to the right of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the statement to indicate how you generally felt while g
you were in the OR. There are no right or wrong answers. 5
Do not spend too much time on any one statement but give ;
the answer which seems to describe your feelings in the F
OR best.
1.1 felt calm-.......... ............................................................................ CD
2, I felt secure........._. ........................................................................... G)
3,1was tense............ ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, G)
4. I was regretful. . . . . . . . . .................................... o
5, I felt at ease ............ ,_,, . ®
6. I felt upset .............. .-.... .................................... CD
7, I was worrying over possible misfortunes. . . . . . . . . ........ . (D
3.1 felt rested........., ____________________________________________________________________________ ®
9, I felt anxious........, _____________________ q)
10. I felt comfortable. . .. ........................ G)
11. I felt self—confident. . . . . . . . . . . . . . ................. G)
12. I felt nervous. . . . . . . . . .............................. G)
13. I was jittery. . - ................................. CD
14. I felt "high strung" ..................................................... G)
15. I was relaxed ...................... (D
16, I felt content ........ ,,,,,,,,,,,,,, G)
17, I was worried ...... . . . . . . ,,,,,,,,,,,,,,,,,,,,,,,,, G)
18. I felt over-excited and "rattled" ,,,,,,,,,,,,,,, G)
19, I felt joyful ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, (D
20, I felt pleasant. . . . . . . . ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, @

CONSULTING PSYCHOLOGISTS PRESS
577 College £2681“, Palo Alto, California 94306

 

LVHMZNOS
08 L'IZLVIBGOW
08 HORN A3311

(9 6') ® 6') ® ® ® ® ® ® ® ® ® ® ® ® ® ® ® ®
® ® C9) @ ® @ ® ® ® ® ® ® ® ® ® ® @ ® ® ®
(9 (9 © (9 (9 C9 G G (9 (9 C9 (9 G I G) G) (9 C9 C9 (9 G)

Number

 

so
14/ Date

 

OPERATING ROOM EXPERIENCE
QUESTIONNAIRE

Complete the following questionnaire based on your observations in the Operating
Room. Please do not discuss any of these questions with any other students

who are participating_in the Project. Results of the questionnaire are for
research purposes only. Your paper will be identified by number only.

1.

10.

11.

12.

Approximate age of the patient (Enter one number only)
Sex of patient Male Female

Skin color of patient

 

What type of operation did you observe? (If you do not know the
scientific name, describe in your own words)

List in order of occurrence what was done to the patient from the time of
your entry into the OR until the incision was made. Be comprehensive
but concise.

How many I.V. lines were started? (Enter one number only)

 

How many I.V. bottles were hung? (Enter one number only)

 

Was an endotracheal tube used? YES NO
Was a ventilator machine used? YES NO

Where was the incision made?

Approximately how long was the incision in inches? (Enter
one number only)

What internal anatomical parts were exposed during the operation?

(OVER)

13.

14.

15.

16.

17.

18.

19.

20.

f.»
\1)
()

Which of the following instruments were used during the operation? (Circle)

A. scalpel G. dissecting scissors
B. Clips H. tissue forceps
0‘. tissue clamp (hemostat) I. suction
D. self-retaining retractor J. extractor
K.

E. hand-held retractor Bovie (electro cautery)
F. right-angle clamp
Was blood transfusion given? YES NO

List the steps in sterile techniques that you observed before and during
the operation. Be comprehensive but concise.

Did the surgeon remark about any unexpected or unusual findings or
pathology during the operation? YES NO

If yes, what were they?

How many, including the surgeon(s), were involved in the handling and
care of this patient while s/he was in the operating room?
(Enter one number only)

 

How many people scrubbed and assisted the surgeon at the operating table
during the operative procedure itself?
(Enter one number only)

 

Was the surgeon right- or left-handed? RIGHT LEFT
Was the patient lying face-up, face-down, or on his/her side:

FACE-UP FACE-DOWN ON SIDE

Number

Date

 

ASPQ - FORM E

1. While you were in the 0R, did you have any unpleasant physiological and/or
emotional reaction(s) to the experience?

YES - Answer questions (2) through (6)
NO - Go to question (6)

2. What reaction(s) did you have? Check those that apply.

Nausea or wooziness short of breath
dizziness shaky
lightheadedness cold and clammy
fainting fear

vomiting loneliness
sweating queasiness
weakness in the knees sadness

blurred vision annoyance at OR personnel
uneasiness tunnel vision
anxiety hot

weakness other (describe)

increased heart rate or
palpitation

3. In general, about how much of the time when you were in the OR did you
feel uncomfortable or have the above reaction(s)?

less than 2 minutes 16-20 minutes 36-40 minutes
2-5 minutes 21-25 minutes 41-45 minutes
6-10 minutes 26-30 minutes over 45 minutes
ll-lS minutes 31-35 minutes
4. Did you leave the OR during the operation? YES NO
If YES, did you return? YES NO

5. How did you cope with your reactions? Check those that apply.
lowered my head
looked away from the surgical field
thought of something else
concentrated on the more objective aspects of the situation
stepped back from the table or moved around
left the OR
other (describe)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
ll.
12.
l3.
14.
15.
l6.
17.
18.
19.
20.
21.
22.
23.
24.
25.

26.
27.
28.
29.
30.

Number
Page 2 4A , Date

A
'/
‘J~

 

 

The purpose of this questionnaire is to identify things that you were sensitive
to while you were in the Operating Room. This sensitivity may have manifested
itself by a physiological and/or emotional response. Using the rating scale,
check the box which best represents how much you were bothered by each
stimulus. There are some stimuli below which you may not have encountered
during this operation. If that is the case, please check "does not apply."

Didn't Bothered Bothered Does not

bother me me apply
me a little a lot
suturing
cutting
shaving

applying bandages
cauterization

expression of pain
wearing scrub suit

wearing mask

intubation

unconsciousness of patient
insertion of IV

nakedness

prepping the skin

blood transfusion
mutilation

smell

surgical instruments
amputation

removing bandages
surgeon's expression of anger
monitors

noise and sounds

presence of IVs

needles

surgeon making disparaging
remarks

incision

blood

retracting

patient vomiting or retching

induction of anesthesia

(OVER)

31.
32.
33.
34.
35.
36.

Page 3

4*.1/

Didn't Bothered
bother me

me a little

helplessness of patient

pus

seeing patient under general
injections anethesia
insertion of urethral catheter

tremor of surgeon's hands

Bothered
me

a lot

Does not
apply

 

ll
12

'll

l)
2)

10.
ll.
12.
l3.

14.

Number

 

‘ ’5"! Date
J.’ "'

SEMANTIC DIFFERENTIAL
SURGEON

 

Instructions: Please rate the concept SURGEON (your concept of SURGEON or
what SURGEON means to you) on the following scales by placing one check mark
per line in the space which indicates how closely related you feel the concept
SURGEON is to one or the other end of the scale:

very quite only neutral only quite very
closely/closely slightly or equally/slightly/ closely closely
good related related related associated related related related bad

 

For example, if you feel that the concept SURGEON is only slightly related to
one side of the following scale as opposed to the other side (but is not really
neutral), then you would place your check here:

good / / X / / / / bad

. or here
good / / / / x / / bad

Place your check-marks in the middle of spaces, not on the boundaries.
Please check each scale using one check per scale.

 

Make each scale a separate and independent judgment. Work fairly rapidly through
the scales. Do not worry or puzzle over individual items. It is your first
impressions, the immediate feelings about the items, that we want. On the other
band, please do not be careless, because we want your true impressions.

 

 

 

 

 

 

 

 

 

 

 

 

 

SURGEON
kind / 1 417 1 [j A?! cruel
unpleasant / / / / / / pleasant
egotistic / / / / / ] altruistic
not compassionate / / / / / / compassionate
repulsive / / / / / / attractive
sensitive / /' / / / / insensitive
caring / / / / / / uncaring
interesting / / / / / / boring
not angry / / / / / g] angry
cooperative / / / / / / uncooperative
unaware / / / / / / aware
flexible / / / c] / j rigid
thoughtful / / / bi] bi] / impulsive
respectful / / / / j_ [_g disrespectful

 

(OVER)

11

§"

Page 2 SELF

very quite only neutral or only quite very
closely closely slightly equally slightly closely closely
good related related related associated related related related bad

 

 

 

 

 

 

 

 

13. thoughtful / / / / / / impulsive

14. respectful / / / / / / disrespectful
15. slow / / / / / / fast

16. passive / / / / / / active

17. humble / / / / / / arrogant

l8. relaxed / / / / / / tense

l9. dishonest / / / / / .1 honest

20. secure / / / / / / insecure

21. calm / / / / / / excitable

 

Aware

a4 Number

 

Date

 

SEMANTIC DIFFERENTIAL

MYSELF IN THE O.R.

Instructions: Please describe yourself as you were for your first twenty min-
utes in the O.R. on the following scales by placing one check mark per line in
the space which indicates how strong y you felt for each scale:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

very moderately somewhat somewhat moderately very
much so so so much so Unaware
For example, if you felt somewhat aware, then you would place your check here
aware I I X I AL I unaware
1) Place your check marks in the middle of spaces, not on the boundaries.
2) Please check each scale using one check per scale.
Make each scale a separate and independent judgment. Work fairly rapidly
through the scales. Do not worry or puzzle over individual items. It is
your first impressions, the immediate feelings about the items, that we
want. On the other hand, please do not be careless, because we want your
true impressions.
MYSELF IN THE O.R.

1. not observant I I u I I observant
2. confident I I II I I frightened
3. alert I I II I I unalert
4. self-aware II I H I I not self-aware
5. impulsive I I II I I thoughtful
6. calm I I H I I_ excitable
7. uncomfortable I I II I ,J comfortable
8. emotional I I H I I unemotional
9. understanding I I H _I I not understanding
10. closed I I H I_g I open
11. subjective I I M I I objective

 

Number

Date

 

SPECIALTY QUESTIONNAIRE

 

Place a check next to the specialty which you plan to enter when you complete
your training. If your planned specialty is not listed, check the specialty
which you think is closest to it and then write your planned specialty in

the space marked "other."

Psychiatry Surgery

Pediatrics Radiology

Family Practice Pathology

Internal Medicine Obstetrics-Gynecology
Other

 

How sure are you of the specialty you plan to pursue?

very sure slightly sure

moderately sure unsure

Please rank these specialties in terms of their attractiveness to you as your
career specialty. Place a "1" next to the specialty which you find most
attractive, a "2" next to the one you find 2nd most attractive, etc. through

£§:_for the one you find least attractive.

 

Psychiatry

Pediatrics

Family Practice
Internal Medicine
Surgery

Radiology

Pathology
Obstetrics-Gynecology

Number

 

in
‘ 0 Date

 

IMPRESSION PARAGRAPH

 

1. In 25 words or less, please describe whatever impressed you about the operating
room experience you just completed.

2. Please make any comments you wish about the Project.

APPENDIX J

INTERIM OBSERVATION FORM

INTERIM OBSERVATION FORM

Number
Date

r—rv

Please indicate below any hospital and medical experience you have

had, especially operations you have observed or assisted.at, since about

June 1, 1980 (experience you have had since you completed the participation

form for this Project). Do not include anyboperations which you have Observed
as part of this Project: ‘ .

Self as patient in surgery

Assistant in childbirth

Had close relative of immediate family
involved in a significant period of
hospitalization

.Assisted in helping-patients in hospital

after surgical operation-

Number of surgical procedures (from minor, e.g.
suturing, to major, e.g. abdominal surgery) observed:

1 2-3 4-6 . Yell 12-20 20*
Emergency Room
Operating Room

Physician's Office

 

 

 

 

 

 

 

 

 

 

Number in which you assisted (scrubbed in and participated):
‘ 1 2-3 4—6 7-1] 12'20 20+

ER
OR
Physician's Office

 

 

 

 

 

l l

 

 

Other clinical medical or surgical
experience — please describe:

141

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