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Concerns in Urologic Education
Vol. 98, July Printed in U.S.A.
TH~ JouRK.AL OF UROLOGY
Copyright © 1967 by The Williams & Wilkins Co.
CONCERNS IN UROLOGIC EDUCATIO~ EDGAR BURNS From the Department of Urology, Ochsner Clinic, New Orleans, Louisiana
The problems encountered in current urologic practice overlap almost every area of clinical medicine; urology, as a specialty, has no strictly confined borders. Therefore, our interest begins in the pre-rn.edical curricula and becomes increasingly intense throughout the period of undergraduate study with culmination at the graduate level. 1Ve are also concerned with the performance of those who complete our training program, as they represent some index of the type of training the program provides. The explosion of scientific information and technical development has necessitated repeated reviews and revision of the undergraduate medical curriculum. Medicine and society continue to change and the demand for better health care has been primarily responsible for the nmny changes that have been made. For a half century, the quality of undergraduate teaching has constituted an index to progress in the development of medical specialties and the present medical curriculum has placed an increased requirement upon the capability of those who apply for admission to the medical school. This has placed an increased responsibility upon the colleges and universities to provide pre-medical students with adequate preparation in the required subjects. Selection of students for admission to the medical sehool is a function of admissions committees and one of the most important phases of medical education. As urologists, v:e should be concerned with this phase of medical education: 1) because of our responsibility to the students during their undergraduate studies and 2) because it is from this group that future urologic residents are ultimately selected. Accepted for publication October 24, 1966. Read at the Symposium on Urologic Education, Duke University Medical Center, Durham, North Carolina, October 21-22, 1966; and at the meeting of the Educational Committee of the American Urological Association, May 28, 1967, held in conjunction with the convention of the Association, in New York, New York, May 29June 1, 1967. Request for reprints: American Urological Association, 1120 North Charles Street, Baltimore, Maryland 21201.
Our next concern is with the individual medical student. The wealth of scientific information has exceeded the ability of the individual human mind to assimilate it during the prescribed period of undergraduate study. Therefore, it has become necessary for the medical student early in his medical education to select a field of interest which, under the leadership of a counselor, will lead him to his ultimate professional career. It is in this early period that the specialty of urology must become identified. The responsibility rests primarily with the chairman of the division of urology, whose qualifications should include scholarly accomplishments, successful experience, teaching ability, creative contributions to the field and enough interest to be willing to make substantial commitments of time and energy to teaching. On the same basis that qualifications of medical students have been increased and their performance made more exacting, changes in the medical school faculty have also become necessary. For many years teaching in the clinical departments of most medical schools was carried out by a parttime, voluntary faculty. Current teaching requirements can no longer be met entirely on a part-time basis. On the other hand, the contributions of the voluntary faculty should be recognized and their participation in the teaching program continued. Because of the clinical nature of their activities, they arc able to bring into the program a slightly different philosophy of attitudes that is important to the training of clinical urologists. IV"hether urology is a separate department in the medical school or a division of general surgery is unimportant. What is important, however, is that each department or division should b:" considered as a unit in the medical educational complex requiring the closest co-operative effort, so that the ultimate goal of professional success may be obtained. Some concern has been expressed both by students and faculty about the changes being made in the undergraduate curricula, in which the student mak('s an early selection of his G
CONCERNS IN UROLOGIC EDUCATION
ultimate career. It should be anticipated that the student's initial interest may change as he progresses toward graduation so that switches from one area of interest to another may be expected. It should also be anticipated that some students will not have decided on a special field of interest by the time of graduation. Faculty performance will have a strong influence on attracting attention to and holding interest in a particular specialty. Here, again, the image of specialty becon1es important. On the other hand, we should not become so preoccupied with our own specialized area of interest to los8 sight of the primary objective of medical education; that is, to educate physicians who will have the desire and the ability to offer the best possible medical care to their patients and, thereby, contribute to over-all health care. Health care is not eonfined to application of therapeutic measures to the individual patient but embodies the broad fields of research and education as well. Each plays an irnportant role in contributing to what is expected of our profession to render total health cane. The greatest demand now is not for a larg,,r nmT1bcr of various medical specialists but for better ways of adapting medical education and practice to current trends. On the same basis that scientific advances have increased the entrance requirements to the undergraduate program, changes in the graduate program also have had to be made. Urologic training in the early period was based on preceptorship. Increased demand for more extensive training: exceeded the capacity of the individual preceptor, so that urologic, as well as other specialty training, had 1o become an institutional function. In a recent report of the J\Iillis commission, it was suggested that some degree of 1n·eceptorship training should be included in selected areas of graduate programs. -Whether thi:, suggestion is to be applied to urologic training is yet to be clecidecl. Approved residencies for all 26 currently existing medical specialties were offered in 1300 American hospitals in 1965. These hospitals are generally of 3 types: l) university hospitals directly under the control of the faeulty of the 85 medical schools, 2) hospitals affiliated with medical schools primarily to supply deficiencies in their own training program and 3) independent community hospitals. The various types of government hospitals are usually under university supervi~ion through the dean's committees. The
general purpose of the training program in each of these is to train qualified urologists. However, the philosophy of these various programs is oriented at a slightly different level ancl the capabilities of the residents may be expected to possess different areas of interest. In the undergraduate program, the ])l'imary emphasis is on education and research with patient care as one of the ultimate objectiws. On the other hand, the primary purpose of the training progran1 in the hospitals is community service through education to qualify urologists to render good service to their patients. Each serves an equally important function_ ln the university hospitals, staffed by the university faculty, two types of programs are often carriPd. on simultaneously. One is directed toward training the physician to practice clinical urology and the other is designed to prepare a selected group of residents for an academic career. vVc arc concerned with the qualifications or those who apply for graduate training. Residents selected for specialty training should lHc subjected to the same critical evaluation used Lo select students for adrn.ission to 1ncdical school. Factors of importance arc their scholarship records in both academic and medical schoob, a,s well as the type and extent of graduate study in preparation for urnlogic training. l t ha::; lwcn repeatedly stated that the essential ingredients arc mental, moral and n1cchanical aHril.mtes. Perhaps the most variable of these is nwntal and it is also the most important beeausc, it constitutes one's ability to develop judgment. Adckd to these should be industry, I'm without the other ingredients would bl, unproductive. At the same time that prospec;tive residents are being subjected to critical evaluation, the.1· should be concerned about the qualifications of those responsible for the training program. They should take full advantage of a privilcgr \\'hirh is theirs to subject the mologic staff to the: same type of critical appraisal. The same amount of time is required for training in an excellent pmgram as in one that is conducted at a lower lPn:l of efficiency. Specialty training requires hard work, long hourn and nrnn~· s1crifices on the part of the resident and his famil~·. The n'siclmit ha,; a right to expect that his effort will be md equal effort on the part of the staff to foundation upon which l]() may attain succes:,. This responsibility mu,;1, lir recogniz<'d and fulfilled in ever? phase of the program.
8
BURNS
The staff should be composed of urologists highly qualified in surgical skill and judgment. The program should be organized and conducted in harn1ony and the chief-of-service should be responsible for the quality of the work done in the department. This should include an interest in teaching and the welfare of the residents, as well as willingness to devote the time and effort required to conduct a good educational program. There are now approximately 230 programs in American hospitals approved for urologic residency training. Of the number of residents trained on these services, more than half are in non-university community hospitals under the direction of a staff without university status. The Residency Review Committee of the Council on Medical Education has established minimal standards of approval that must be met by all of these programs. On the other hand, there is a wide difference between the program that meets minimum requirements and the one that provides exceptional training. Concern has been expressed that these marginal programs use residents too much for routine patient care rather than for the primary purpose of postgraduate education. This is an area to which attention should repeatedly be directed. Repeated reviews and revisions of standards to provide more proficient performance may be expected to continue and further changes may be expected to be made as demands become more exacting. \Vith progressive development, such changes certainly will be made. Iviuch concern has been expressed regarding the dwindling number of service patients available for residency training. This was first expressed in medical circles when millions of Americans began to take advantage of the various types of prepaid medical care and hospital insurance, converting many service patients to a private status. With the advent of :Vledicare and the various types of federally financed medical programs, we now have almost universal medical insurance, so that in effect there are no more charity patients, who in the past provided operative experience for the residents. This has created problems for graduate training in the surgical specialties, for which solutions must be found. The current refusal of many of the insurance companies to pay for operations performed by the resident will undoubtedly have to be revised. Perhaps our own philosophy regarding the importance of solo experience by the surgical resident should be
reviewed. There are many examples of excellent training in the surgical specialties conducted in medical centers which care priniarily for private patients. As evidence of the excellence of these programs, their graduates can be found in positions of leadership in educational centers throughout the world. Whatever the current problems with which we are faced, it should not be anticipated that the level of medical education will decline or that the standard of medical practice will be lowered. One of the most important facets of any train-ing program is that the resident become familiar with the physiologic alteration that creates the clinical problem with which he is confronted and that he understand the influence of changes that occur in one area on the function of other systems. It is important that the resident learn through study and in the capacity of an assistant how to perform a surgical procedure correctly, as well as how to care for the patient in the postoperative period especially, how to recognize and treat complications that may arise. The opportunity to observe and to work with skilled surgeons should be assessed at its proper value. All these factors constitute a part of the foundation of sound medical education that should start in the undergraduate period. The expansion of knowledge that has created the need for specialization is also leading to some degree of fragmentation within a specialty with which we are involved to some extent at the present time. Whatever the degree of fragmentation, or separation of specialized areas of interest, effective means of communication and collaboration must be established and maintained. The current pressure from both within and without the rn.edical profession for the total health care of the population has created added emphasis on preventive medicine, as well as efforts to cure those who have become ill. Scientific advances that have provided effective means of sustaining life have created a large segment of chronically ill patients. This group may 112 of value for academic teaching and research but does not offer a significant contribution to clinical urologic training. There is now a preponderance of patients with far advanced diseases and fewer patients with early or short-term diseases who find their way into community hospitals. Concern has been expressed about our declining professional image. Much of this has been at--
CONCEHNS IX UROLOGIC EDUCATJON
tributed to the expansion of knowledge that has led to increased specialization. As specialists, we are too pre-occupied with the instruments of precision that have been placed in our hands and the results that can be obtained by their use, to give much tbought to the patient as an individual. Eduealion that supplies only knowledge without developing; a eoncern for human \·alucs is incomplete. We should remember that tbe patients we are treating today have the same sc~nsitivities and shmv the sarn.e response to kindly consideratiou of their problems as those treated by our forcfatlwr gccncral practitioner, who knew the ,social and economic background of all of his
9
patients. Perhaps it would be well for us l u continue to remind ourselves that we are sicians, not craftsmen, that ours is a profession and not a trade, ancl that in our training program this should be emphasized along with the development of scientific: knowledge urn! technical skilL l(EFEHENCES
CASELEY, D. J. The Honse Physicim1 Hcporte1 September-October, Hll\o, p. 3. !Vln,Lrn HE PORT: The (;rndnate Edncal io11 ni" T'hysicians. The H.eport of the Citi7,e11's Comm1ss10n on Grnduate Medical E(lucatio11. American ;\leclical Association, Chic:ago. Illinois.
TH~ JouRK.AL OF UROLOGY
Copyright © 1967 by The Williams & Wilkins Co.
CONCERNS IN UROLOGIC EDUCATIO~ EDGAR BURNS From the Department of Urology, Ochsner Clinic, New Orleans, Louisiana
The problems encountered in current urologic practice overlap almost every area of clinical medicine; urology, as a specialty, has no strictly confined borders. Therefore, our interest begins in the pre-rn.edical curricula and becomes increasingly intense throughout the period of undergraduate study with culmination at the graduate level. 1Ve are also concerned with the performance of those who complete our training program, as they represent some index of the type of training the program provides. The explosion of scientific information and technical development has necessitated repeated reviews and revision of the undergraduate medical curriculum. Medicine and society continue to change and the demand for better health care has been primarily responsible for the nmny changes that have been made. For a half century, the quality of undergraduate teaching has constituted an index to progress in the development of medical specialties and the present medical curriculum has placed an increased requirement upon the capability of those who apply for admission to the medical school. This has placed an increased responsibility upon the colleges and universities to provide pre-medical students with adequate preparation in the required subjects. Selection of students for admission to the medical sehool is a function of admissions committees and one of the most important phases of medical education. As urologists, v:e should be concerned with this phase of medical education: 1) because of our responsibility to the students during their undergraduate studies and 2) because it is from this group that future urologic residents are ultimately selected. Accepted for publication October 24, 1966. Read at the Symposium on Urologic Education, Duke University Medical Center, Durham, North Carolina, October 21-22, 1966; and at the meeting of the Educational Committee of the American Urological Association, May 28, 1967, held in conjunction with the convention of the Association, in New York, New York, May 29June 1, 1967. Request for reprints: American Urological Association, 1120 North Charles Street, Baltimore, Maryland 21201.
Our next concern is with the individual medical student. The wealth of scientific information has exceeded the ability of the individual human mind to assimilate it during the prescribed period of undergraduate study. Therefore, it has become necessary for the medical student early in his medical education to select a field of interest which, under the leadership of a counselor, will lead him to his ultimate professional career. It is in this early period that the specialty of urology must become identified. The responsibility rests primarily with the chairman of the division of urology, whose qualifications should include scholarly accomplishments, successful experience, teaching ability, creative contributions to the field and enough interest to be willing to make substantial commitments of time and energy to teaching. On the same basis that qualifications of medical students have been increased and their performance made more exacting, changes in the medical school faculty have also become necessary. For many years teaching in the clinical departments of most medical schools was carried out by a parttime, voluntary faculty. Current teaching requirements can no longer be met entirely on a part-time basis. On the other hand, the contributions of the voluntary faculty should be recognized and their participation in the teaching program continued. Because of the clinical nature of their activities, they arc able to bring into the program a slightly different philosophy of attitudes that is important to the training of clinical urologists. IV"hether urology is a separate department in the medical school or a division of general surgery is unimportant. What is important, however, is that each department or division should b:" considered as a unit in the medical educational complex requiring the closest co-operative effort, so that the ultimate goal of professional success may be obtained. Some concern has been expressed both by students and faculty about the changes being made in the undergraduate curricula, in which the student mak('s an early selection of his G
CONCERNS IN UROLOGIC EDUCATION
ultimate career. It should be anticipated that the student's initial interest may change as he progresses toward graduation so that switches from one area of interest to another may be expected. It should also be anticipated that some students will not have decided on a special field of interest by the time of graduation. Faculty performance will have a strong influence on attracting attention to and holding interest in a particular specialty. Here, again, the image of specialty becon1es important. On the other hand, we should not become so preoccupied with our own specialized area of interest to los8 sight of the primary objective of medical education; that is, to educate physicians who will have the desire and the ability to offer the best possible medical care to their patients and, thereby, contribute to over-all health care. Health care is not eonfined to application of therapeutic measures to the individual patient but embodies the broad fields of research and education as well. Each plays an irnportant role in contributing to what is expected of our profession to render total health cane. The greatest demand now is not for a larg,,r nmT1bcr of various medical specialists but for better ways of adapting medical education and practice to current trends. On the same basis that scientific advances have increased the entrance requirements to the undergraduate program, changes in the graduate program also have had to be made. Urologic training in the early period was based on preceptorship. Increased demand for more extensive training: exceeded the capacity of the individual preceptor, so that urologic, as well as other specialty training, had 1o become an institutional function. In a recent report of the J\Iillis commission, it was suggested that some degree of 1n·eceptorship training should be included in selected areas of graduate programs. -Whether thi:, suggestion is to be applied to urologic training is yet to be clecidecl. Approved residencies for all 26 currently existing medical specialties were offered in 1300 American hospitals in 1965. These hospitals are generally of 3 types: l) university hospitals directly under the control of the faeulty of the 85 medical schools, 2) hospitals affiliated with medical schools primarily to supply deficiencies in their own training program and 3) independent community hospitals. The various types of government hospitals are usually under university supervi~ion through the dean's committees. The
general purpose of the training program in each of these is to train qualified urologists. However, the philosophy of these various programs is oriented at a slightly different level ancl the capabilities of the residents may be expected to possess different areas of interest. In the undergraduate program, the ])l'imary emphasis is on education and research with patient care as one of the ultimate objectiws. On the other hand, the primary purpose of the training progran1 in the hospitals is community service through education to qualify urologists to render good service to their patients. Each serves an equally important function_ ln the university hospitals, staffed by the university faculty, two types of programs are often carriPd. on simultaneously. One is directed toward training the physician to practice clinical urology and the other is designed to prepare a selected group of residents for an academic career. vVc arc concerned with the qualifications or those who apply for graduate training. Residents selected for specialty training should lHc subjected to the same critical evaluation used Lo select students for adrn.ission to 1ncdical school. Factors of importance arc their scholarship records in both academic and medical schoob, a,s well as the type and extent of graduate study in preparation for urnlogic training. l t ha::; lwcn repeatedly stated that the essential ingredients arc mental, moral and n1cchanical aHril.mtes. Perhaps the most variable of these is nwntal and it is also the most important beeausc, it constitutes one's ability to develop judgment. Adckd to these should be industry, I'm without the other ingredients would bl, unproductive. At the same time that prospec;tive residents are being subjected to critical evaluation, the.1· should be concerned about the qualifications of those responsible for the training program. They should take full advantage of a privilcgr \\'hirh is theirs to subject the mologic staff to the: same type of critical appraisal. The same amount of time is required for training in an excellent pmgram as in one that is conducted at a lower lPn:l of efficiency. Specialty training requires hard work, long hourn and nrnn~· s1crifices on the part of the resident and his famil~·. The n'siclmit ha,; a right to expect that his effort will be md equal effort on the part of the staff to foundation upon which l]() may attain succes:,. This responsibility mu,;1, lir recogniz<'d and fulfilled in ever? phase of the program.
8
BURNS
The staff should be composed of urologists highly qualified in surgical skill and judgment. The program should be organized and conducted in harn1ony and the chief-of-service should be responsible for the quality of the work done in the department. This should include an interest in teaching and the welfare of the residents, as well as willingness to devote the time and effort required to conduct a good educational program. There are now approximately 230 programs in American hospitals approved for urologic residency training. Of the number of residents trained on these services, more than half are in non-university community hospitals under the direction of a staff without university status. The Residency Review Committee of the Council on Medical Education has established minimal standards of approval that must be met by all of these programs. On the other hand, there is a wide difference between the program that meets minimum requirements and the one that provides exceptional training. Concern has been expressed that these marginal programs use residents too much for routine patient care rather than for the primary purpose of postgraduate education. This is an area to which attention should repeatedly be directed. Repeated reviews and revisions of standards to provide more proficient performance may be expected to continue and further changes may be expected to be made as demands become more exacting. \Vith progressive development, such changes certainly will be made. Iviuch concern has been expressed regarding the dwindling number of service patients available for residency training. This was first expressed in medical circles when millions of Americans began to take advantage of the various types of prepaid medical care and hospital insurance, converting many service patients to a private status. With the advent of :Vledicare and the various types of federally financed medical programs, we now have almost universal medical insurance, so that in effect there are no more charity patients, who in the past provided operative experience for the residents. This has created problems for graduate training in the surgical specialties, for which solutions must be found. The current refusal of many of the insurance companies to pay for operations performed by the resident will undoubtedly have to be revised. Perhaps our own philosophy regarding the importance of solo experience by the surgical resident should be
reviewed. There are many examples of excellent training in the surgical specialties conducted in medical centers which care priniarily for private patients. As evidence of the excellence of these programs, their graduates can be found in positions of leadership in educational centers throughout the world. Whatever the current problems with which we are faced, it should not be anticipated that the level of medical education will decline or that the standard of medical practice will be lowered. One of the most important facets of any train-ing program is that the resident become familiar with the physiologic alteration that creates the clinical problem with which he is confronted and that he understand the influence of changes that occur in one area on the function of other systems. It is important that the resident learn through study and in the capacity of an assistant how to perform a surgical procedure correctly, as well as how to care for the patient in the postoperative period especially, how to recognize and treat complications that may arise. The opportunity to observe and to work with skilled surgeons should be assessed at its proper value. All these factors constitute a part of the foundation of sound medical education that should start in the undergraduate period. The expansion of knowledge that has created the need for specialization is also leading to some degree of fragmentation within a specialty with which we are involved to some extent at the present time. Whatever the degree of fragmentation, or separation of specialized areas of interest, effective means of communication and collaboration must be established and maintained. The current pressure from both within and without the rn.edical profession for the total health care of the population has created added emphasis on preventive medicine, as well as efforts to cure those who have become ill. Scientific advances that have provided effective means of sustaining life have created a large segment of chronically ill patients. This group may 112 of value for academic teaching and research but does not offer a significant contribution to clinical urologic training. There is now a preponderance of patients with far advanced diseases and fewer patients with early or short-term diseases who find their way into community hospitals. Concern has been expressed about our declining professional image. Much of this has been at--
CONCEHNS IX UROLOGIC EDUCATJON
tributed to the expansion of knowledge that has led to increased specialization. As specialists, we are too pre-occupied with the instruments of precision that have been placed in our hands and the results that can be obtained by their use, to give much tbought to the patient as an individual. Eduealion that supplies only knowledge without developing; a eoncern for human \·alucs is incomplete. We should remember that tbe patients we are treating today have the same sc~nsitivities and shmv the sarn.e response to kindly consideratiou of their problems as those treated by our forcfatlwr gccncral practitioner, who knew the ,social and economic background of all of his
9
patients. Perhaps it would be well for us l u continue to remind ourselves that we are sicians, not craftsmen, that ours is a profession and not a trade, ancl that in our training program this should be emphasized along with the development of scientific: knowledge urn! technical skilL l(EFEHENCES
CASELEY, D. J. The Honse Physicim1 Hcporte1 September-October, Hll\o, p. 3. !Vln,Lrn HE PORT: The (;rndnate Edncal io11 ni" T'hysicians. The H.eport of the Citi7,e11's Comm1ss10n on Grnduate Medical E(lucatio11. American ;\leclical Association, Chic:ago. Illinois.