This study highlights the prevalence of operating theatre related syncope among medical students, and demonstrates the potentially damaging affect of this phenomenon in discouraging students from pursuing a surgical career.
Attending operations is an essential part of surgical placements at medical schools. In addition, observing and assisting in surgical procedures has been shown to improve students understanding of surgical pathologies and clinical anatomy [5
Adapting to the new environment of the operating theatre has been shown to be one of several challenges facing medical students at the start of their surgical clerkships [6
]. One major element is the anxiety surrounding the potential for syncopal episodes in the operating theatre [4
The UK Medical Research Group identified that 44.9% of its' respondents believe their ultimate choice of career had been influenced by their undergraduate experience of a speciality [7
]. This undergraduate experience has gained even more significance in the United Kingdom following the introduction of the Modernising Medical Careers initiative. Career choices must be made earlier, with reduced flexibility and time in training further reducing the experience that graduates obtain in a given field prior to specialising. This study indicates that operating theatre related syncope can affect students' choice of career and discourage students from pursuing surgery. This becomes worrisome when one considers the gradual decline in numbers of junior doctors pursuing a career in general surgery [8
This study highlights the impact student experience of the operating theatre can have on their interest in a surgical career. Sixteen percent of students who were interested in pursuing this indicated that they were put off as a result of their syncopal episodes. This may be due to the anxiety that syncopal episodes can cause. Frequent episodes of operating theatre syncope can also reduce the confidence of a medical student in his or her ability to become a surgeon.
Concerns have previously been raised about the potential safety hazard of medical students in theatre, given their reduced experience and knowledge of procedures and aseptic techniques [9
]. A lack of appropriate student preparation in their course prior to attending the operating theatre no doubt increased these risks.
Our study shows a high prevalence of operating theatre related syncope among medical students with over 1-in-10 clinical students reporting at least one episode of near or actual syncope. Although two previous studies have reported syncope rates amongst medical students [10
], we are not aware of any studies that have specifically investigated this in the operating theatre setting. Ganzeboom et al demonstrated that syncope in young adults is common, with 1-in-3 expected to have had at least one episode in their life time [10
]. Serletis et al found that gender and family history were important predictors of syncope in medical students, and noted a similar syncopal event rate of 32% [11
This study identifies hot temperature and prolonged standing to be the major predisposing factors for syncopal episodes, which is consistent with the previous work in this area [10
]. Our study also demonstrates that being scrubbed does not predispose students to a higher risk of syncope as 48% of episodes occurred when students were not scrubbed. Furthermore, 16% of episodes occurred during laparoscopic surgery, suggesting that sight of the operation remains a strong contributory factor even when the associated stimulations of open surgery are removed.
None of the reactants in this study identified needle or blood phobias as a cause of their syncopal attacks. This has been demonstrated as a major cause of vasovagal syncope in members of the public [12
]. This difference may lie in the fact that those with severe blood and needle phobias may be deterred from entering medical careers.
A statistically significant difference in the incidence of syncope exists between genders in this study. This is consistent with the work carried out by Fu et al and Ganzeboom et al which demonstrated a higher rate of syncope among women in comparison to men. The aetiology of this remains unclear and various mechanisms such as smaller hearts, lower vascular resistance and the hypo-adrenergic response of women have been proposed [13
]. The increased willingness of female medical students to own up to their syncopal episodes can also contribute to the increased reported prevalence of such episodes [10
The reported variation in frequency of episodes between different surgical specialities was not statistically significant. Irrespective of this, these figures would reflect the different operating theatre opportunities available in different medical school placements.
Previous studies have described how prior teaching and preparation for theatres such as theatre tours and information on theatre etiquette can improve theatre based learning [14
]. The high prevalence of syncopal episodes in our study indicates a greater need for students to be informed of potential dangers, contributory factors and preventative measures as part of such induction programmes. Wieling et al highlighted several physical manoeuvres such as leg crossing, muscle tensing and squatting that are effective at combating orthostatic intolerance [16
]. Instruction on such manoeuvres or direction towards syncope advice groups may be of use for students commencing their surgical attachments [17
]. The results of this study indicate that self-initiated preventative measures, such as eating prior to attending theatre were considered successful by students.
Universities should reflect on the trend towards rising proportions of female medical students, given the importance of undergraduates gaining experience in surgical specialities. The higher prevalence of syncope among females should not be allowed to discourage these students from gaining experience in this area or pursuing a surgical career.
As with any questionnaire survey, a degree of responder bias may affect these results. It is therefore important to note that any under-reporting in this study strengthens the results by further increasing the prevalence of operating theatre related syncope. Given the findings from more generalised medical student studies of a higher syncopal event rate [10
], it is likely a degree of under-reporting has indeed occurred. However, students who have taken part in this study may not have had equal exposure to operating theatres as attendance may be dependent on the student's underlying interest in surgery.
Finally this study reports the experience of one UK medical school. Although low rates of theatre instruction and a lack of student information have been previously reported at other UK medical schools [14
] it is unclear as to what degree these results may be extrapolated elsewhere.
We hope that research groups will seek to confirm these findings in other surgical and educational settings. Further studies are then required to devise and assess the effectiveness of different educational measures in addressing operating theatre related syncope. One medical school, recognising the limited preparation students receive for the operating theatre, has recently developed an instructional DVD and learning guide into which such material might be incorporated [18
]. It is hoped that this work will increase medical students' educational opportunities in the operating theatre, whilst reducing anxiety and stimulating students to pursue a surgical career.