Student internship (SI) is a component of the clinical education program for fourth-year students offered by most medical schools in the United States [1]. Originally, the SI was initiated to compensate for the shortage of resident resources during World War II. In such a program, unlike the third-year clerkship, senior medical students served as interns with progressively graded clinical responsibility, which had originally been the role of residents [2].

Nowadays, the SI is considered as a program to prepare fourth-year students for the first year of postgraduation [3]. The SI offers greater and complex clinical exposure to student interns, which enhances their experience in handling physicians' tasks [4,5]. Thus, the SI integrates clinical knowledge, skills, and attitudes before graduation, and can reduce the transition gap from the third-year clerkship to the first year of postgraduation. It has been recommended that such SI programs should allow fourth-year students to replace the first postgraduate year completely, under the supervision of senior house staff [3].

Several studies have suggested that the SI should be incorporated into the undergraduate medical education in Korea [6,7]. The Korean Academy of Medical Sciences [7] pointed out that the current intern training system is inefficient and that the duration of residency training should be modified. The Academy had proposed the abolishment of the intern training system and that SI in the undergraduate curriculum could replace some part of the intern program [8]. Some schools have reported successful implementation of the SI program [9,10]. Thus, SI is expected to be established nationwide in the future.

However, whether SI is feasible in Korea, especially in the surgery department, has not been determined. SI has not yet gained popularity in Korea, and Korean patients and health care professionals are not accustomed to a system in which medical students take up the role of an intern [9]. Furthermore, previous articles about SI usually covered SI in only internal medicine [3,11,12,13,14]. Articles about SI in surgery [15,16] are rare and examined only a limited number of issues. In addition, the Korean Association of Medical Colleges (KAMC) and the Korean National Licensing Exam for Clinical Skills Exam announced the competencies that graduates need to achieve. However, there is as yet no nationwide study that explored if it is feasible for students to be in charge of such clinical tasks during a surgical SI program in the Korean context.

Surgical educators should prepare for the nationwide introduction of the SI program. When setting up SI in surgery, the features of surgery should be considered. To develop a program that is safe for both patients and students in Korea, we should understand which tasks student interns can perform in real surgical situations in Korea. To understand the circumstances in surgical education in Korean hospitals, we should first examine the current situation of hospitals. Each training hospital may have a different curriculum and training environment. Patients' problems and disease entities can differ according to the characteristics of the region or hospital system.

The present study therefore investigated which tasks surgical student interns could perform in a hospital in Korea, and discussed the requirements for the successful implementation of a surgical SI program.

This study is the first such nationwide study in Korea. We tried to investigate the Korean surgical context and surgical educators' perspectives. Students' experience in surgery is expected to be different from those in internal medicine. Clinical practice in surgery includes participation in operations and perioperative care. Competent procedural skills and prompt decision-making are needed while managing surgical patients. This study can be helpful for educators who wish to introduce an SI program in their institution, which previously had no such program.

The present study showed that 21 schools did not have any SI programs in surgery. The questionnaire in this study did not ask whether these schools had an SI program or why they did not implement SI in surgery. However, it is reasonable to assume that their surgical departments were not required to have SI programs because their medical schools did not encourage such programs.

This study revealed that there is a misconception about SI. Only five schools offered the SI program to final-year students. Some schools did not discriminate between SI and clinical clerkships. These findings indicate that the role of student interns is unclear. When establishing an SI program in a medical school and hospital, it is desirable to share the definition and explicit role of student interns with all members in the medical schools and hospitals. The SI is often termed as "subinternship," but the term "subintern" creates further confusion about the role of student interns. The term "subintern" may indicate being "subordinate to an intern," which is incorrect. The actual role of a student intern is a student physician in charge. Therefore, we think "student interns" or "student physicians in charge" are more suitable compared to "subintern."

In studies conducted in the United States, student interns in surgery cited patient and perioperative care events as the most frequent critical incidents [15]. These are surgery-specific tasks that surgical educators should offer to surgical student interns. However, our results showed that it is less possible for Korean student interns to perform surgery-specific tasks in an SI. Among the tasks given to students, while it was considered acceptable for them to assist in a surgery, it was reported as inappropriate to involve them in postoperative care. This means that even though students could choose a surgical SI in order to prepare to be surgeons, they would not be able to experience enough relevant activities during the SI. Students can experience activities such as history taking, physical examination, and reporting a patient's status during an SI in other departments such as internal medicine or pediatrics. Studies have found that students desired to improve their skills related to basic surgical patient care and knowledge in the field of surgery, and that surgical SI influences many students when they choose a specialty [16]. Therefore, an SI program in surgery should provide surgery-specific tasks to student interns.

We recommend 12 tasks for surgical student interns: (1) surgical patient encounters such as history taking, physical examination, and patient education; (2) medical recording; (3) reporting a patient's status; (4) preoperative management; (5) entering orders; (6) obtaining informed consent; (7) performing basic procedures; (8) assisting surgeries in the operation theatre; (9) prevention and early detection of surgical complications; (10) working in the night duty; (11) personal and professional development; and (12) team work. Breast and anorectal exam is an essential part of the physical examination conducted in surgery. Therefore, we suggest not avoiding these examinations. Some faculties and residents encourage their student interns to review textbooks or join a journal club, but it is desirable to allow student interns to perform more practical tasks in the surgical field.

Among the symptoms, signs and diseases, acute abdomen and heat/cold injuries are surgery-specific areas. However, our study revealed that it was less possible for student interns to encounter them. We recommend that surgical educators include abdominal pain, neck mass, abdominal or inguinal mass, anorectal symptoms, breast symptoms, and soft tissue infections as major symptoms and signs that student interns encounter in surgery. We think that student interns should be able to care for cancer patients unless these patients are expected to have severe surgical complications. We expect that student interns can manage basic gastrointestinal cancer, thyroid neoplasm, hernia, benign anorectal diseases, breast neoplasm, and soft tissue abscess without complications as a primary charge.

Our study also revealed that it was highly possible for students to perform technical skills rather than other tasks. This implies that the Korean hospital context favors technical skill performance of the students. Lindeman reported that most surgery student interns evaluated technical skills education as helpful [16]. We recommend that the training of student interns focuses on technical skills related with surgical procedures. Surgery-specific skills training such as wound dressing, sutures, local anesthesia, and abscess incision and drainage is meaningful for student interns in surgery.

Societal and system support should take precedence in order for SI to take root in Korea. Kim [19] emphasized the limitation of legal practice in clinical practice for student interns, even though he confirmed the logistical authorization of medical student's active participation in clinical practice for their learning. Student interns' ordering is expected to be the most difficult part to establish when considering the Korean clinical context. Therefore, we think that the legal regulations should be modified first. To improve patient safety, it could be helpful to verify if the student is competent enough to encounter a patient as a student intern before entering an SI program.

In addition, to ensure appropriate implementation of SI in surgery, curriculum improvement and perception change of educators and students is necessary. We should focus more on educational continuity from undergraduate education through graduate medical education. Clinical clerkship in the third year should allow medical students to participate in their practice more actively, to guarantee patient safety during their SI. Preclerkship curriculum should support students in honing their ability to care for patients safely. During the SI, educators should support students in integrating their clinical experience and competencies in an individualized manner. Assessment and evaluation should also be improved. Cacamese et al. [20] reported grade inflation in internal medicine SI. In addition, student interns should be treated as students, not employees. SI directors have to understand what student interns are, and what duties they should perform. Medical schools and departments of surgery should support subinternship directors in their coordination of the SI program in surgery [21].

This study has some limitations. First, the questionnaire that was developed for this study was not piloted. Second, we restricted our methodology to a survey, and did not include complementary tools such as interviews. Therefore, we could not explore the underlying background or obstacles more specifically. Third, we performed the survey nationally, but nine schools did not respond to the survey despite repeated attempts. Fourth, we cannot verify whether the respondents had adequate knowledge of the definition of SI or concept of curriculum.

In conclusion, it is necessary to determine a specific role for student interns, encourage student interns to perform surgeryspecific tasks, provide societal and system support, and conduct curriculum renovation to establish the SI program.