Conference workgroups and summation1

The American Journal of Surgery 184 (2002) 225–251

Conference dialogue

Conference workgroups and summation Moderated by Hiram C. Polk, Jr., M.D.* Ben A. Reid, Sr., Professor and Chairman, Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA Dialogue from the Symposium on Challenges in Surgical Education: Competencies, Work Hours, Workforce, Assessment, and Adaptation, May 8 –9, 2002, Louisville, Kentucky Manuscript received May 30, 2002; revised manuscript June 21, 2002

Dr. Hiram C. Polk, Jr. (Louisville, KY): Many of you have taken part in conferences that are in this format. You know the fun part was yesterday, hearing new ideas from people who had different views about important issues. The second fun part was getting into small groups and trying to find one or two “bones to chew on” to develop a position where it means something to everybody. The hard work of something like this inevitably comes in these sessions, where you must make some sense out of what were often very global or transcendent issues. What we’re going to do this morning is try to devote 15 minutes or less to each group’s report. Let us focus on that report, listen to the presentation, try to highlight three or four things out of that, and then come to the next phase of the morning in which we try to take those ideas and see what are 8 or 10 things that we can actually do and want to implement. I am just going to serve as moderator, and Dr. Taylor and I are going to be secretaries. There were two things that came up yesterday that were so different that you must psychologically put them aside. The first of those was: Is there some way within the existing pay structure to provide some significant benefits for house officers who are going the extra mile that would directly help them with their debt load? Many of you didn’t hear that, but is there a capacity where we could— consistent with resident duties and university employees—ask why aren’t they eligible for a pension fund and why couldn’t that pension fund be targeted to the impossible issues of debt that are very significant for residents in surgery? The second issue that transcended some other things was a very good idea. Why are we one of the few medical groups in the world without a patient advocacy group to speak up for us and without a group to go with us to Congress and represent the best of what surgery has to offer? They were the two freshest ideas from yesterday that may or may not * Corresponding author. Tel.: ⫹1-502-852-5442; fax ⫹1-502-8528915.

come up in our group report, but we do not want to lose them.

Workgroup I How to implement and fund core competencies in surgery Dr. Polk: Doctor Itani, could we start with the hard issue of how to implement and fund core competencies in surgery, and what am I going to do with 5000 data points on each of my residents? Dr. Kamal Itani (Houston, TX): We had a very interesting group and a lively discussion yesterday. The group was very representative of this medical center, in that you would look around and some people haven’t even heard about what core competencies are! The first thing we did was to put the core competencies on our sheet and go over them within the group. Then, we tried to go over the various institutions that the group represented and see, within their Departments of Surgery, whether the core competencies were covered within the curriculum, and there was a unanimous “no” within the group, that the core competencies were not covered. Then we said how about knowledge? Don’t you cover knowledge within your Department of Surgery? There was a unanimous “yes,” we do cover knowledge. Grand rounds, journal clubs, various conferences, and so everybody was satisfied that within their Departments that knowledge was covered. How about patient care? Do you cover patient care issues? The group was again unanimous about patient care issues, stating that patient care is very well covered. The group stated that they do have patient care issues that they cover with their residents. They go over the choice of diagnostic tools, the choice of therapeutic measures, and then they assess the residents based on the care they have provided.

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How about professionalism? Here we started a thinking process. What is it that we are trying to do with professionalism within our institutions in the Department of Surgery? Vanderbilt had done something very interesting at the institutional level. They went through a series of six lectures, each lecture presented twice so that they can capture as much audience as possible. They had issues of professionalism, ethics, and communications that were covered within this series of lectures. However, they were not very satisfied with the attendance. The residents’ attendance was about 35% to 50%, at best. At Baylor, we had the exact same scenario. We had a series of eight lectures that were instituted from the GME office, and they covered issues of ethics, end-of-life decision-making, patient expectations, and the attendance was also close to 40% or 45%. So Vanderbilt and Baylor had the exact same experience. However, Vanderbilt had done something more interesting. They have developed a quiz that is Web-based, where the resident will log on to the computer and take a fivequestion quiz to answer questions related to the topic that was covered. In addition, there were some of these topics that were also incorporated in grand rounds, other conferences, and rounds. During mortality/morbidity conference, some issues of professionalism were discussed and end-oflife issues that were discussed in the SICU. If you come to Louisville and see what is going on, there were similar topics that were covered in conferences and walk rounds. This was very interesting. Two PhD ethicists make SICU rounds 75% of the time and make contributions to difficult issues in the SICU. Dr. Polk: That’s been an interesting thing. We wrote about it decades ago [1]. It’s different. Dr. Itani: Well, this covers the issue of professionalism, and then there is sometimes a psychiatrist that contributes in trauma and in the SICU. Louisville also has conferences in addiction medicine, and somebody in the trauma area would help with people who are addicted and have substance abuse. Dr. Polk: That is a pearl. We have a generalist who has done extra training as an addiction medicine specialist. Three fourths of our patients are in the ICU indirectly because of problems with alcohol or tobacco, or street drugs, and he has a special role. There just aren’t enough of them for you to depend on very much, but he is very valuable. Dr. Itani: So you can see now that you have three institutions. Most of the people were not aware that they were covering areas of professionalism within their curriculum, and yet here they are. They are available, but we didn’t know that we were covering this area of core competency. Then we moved into the area of interpersonal skills, and at Louisville, something came up that’s very interesting. The interdisciplinary medicine-surgery conference that they have establishes interdisciplinary communication skills, which the student who was present with us and the faculty thought was really a very good example of how to establish

interdisciplinary communication and take advantage of the expertise of other people. We have the same thing at Baylor as does Vanderbilt. Again, we have covered, in some ways, the area of interprofessional and interpersonal skills. Now, we didn’t talk about how you communicate with patients, but we did touch on the issues of race, gender, and how to deal with a difficult resident who has problems in these areas. Then came a very interesting idea, which is role modeling. We all agreed that we have some people within our faculty and departments that do act as role models, and who are actually behaving every day in the operating room, in the clinic, in conferences as role models for residents and students. This is also a fine way to teach professionalism, by role modeling. Dr. Polk: That can be both a positive and negative role, and the negative role is just awful. I was visiting at a well-known medical center a few weeks ago, and one of the problems they posed during what was a rather long confessional was that they had not had anybody from their medical school choose to do an internship there in general surgery in a decade. That is a pretty striking observation. There was a very bright young woman faculty, in her third or fourth year, and she said, “Doctor Polk, that’s simple.” These old guys have been spending the whole conference talking about how it used to be and how bad it is now, and, “I cannot imagine anybody coming to do a rotation with us and then choosing to do their residency in this hospital with that pervading atmosphere.” The role modeling we think about is good. Gratuitous bad things are an issue, and that the senior people, no matter what, give the overriding impression, whether they’re numerous or not. Dr. Itani: It is a very, very good example, and I completely agree. It’s going to be the prerogative of the leaders of our departments and institutions to take care of those particular individuals and direct them to proper role modeling. We had more difficulty with practice-based learning and improvement. However, we all decided that we are probably best, within surgery, to address this core competency; the Mortality and Morbidity Conference is a gold mine. We went over what we did at the Houston VA. We changed “mortality and morbidity” to call it a Quality Improvement Conference.

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Dr. Polk: That is a priceless label. Dr. Itani: We are not going to look at your mistake, and say you made a mistake. We’re going to look at the overall system. An example. Let’s say that your patient develops C. difficile colitis, a complication that happened a few days after surgery. We’re going to start looking at the antibiotics and for how long you gave the antibiotics, as you know is proper. However, we want to also look at the system, and we want to see if something happened within the ICU or on the ward, if other patients are having C. difficile colitis, and try to address it from a system standpoint, from our practice within the hospital. Is there anything going wrong within the hospital? Is somebody not washing their hands, going from one patient to the other and spreading the C. difficile? That’s just an example. A patient like this, we would ask the resident to research the topic, meet with the infectious disease nurse, and come up with the data and present the data at the next quality improvement conference. This is how you improve your practice. Everybody learns from it, and you improve the way you are practicing medicine. Dr. Claude H. Organ, Jr. (Oakland, CA): Before you go on, is that going to comply with the RRC guidelines for a mortality-morbidity conference? Is it going to meet the requirement? Dr. Doris A. Stoll (Chicago, IL): I think if, for example, whatever you describe what you do in your M&M conference, you link them to these objectives with practice-based learning, the answer is “yes.” Dr. Itani: It’s very important that you, Dr. Organ, take it from the context of our traditional mortality-morbidity conference, give it a different name, and stick with what that name implies—“quality improvement.” System-based practice—we get, hopefully, not too many root cause analyses to do in the hospital. We need to involve the residents with those root cause analyses. This is a perfect example of how to set up system-based practice. We have also an amazing wealth of institutions here. Each one of them has a different setup and draw a different patient population. Each patient population has different needs, and it is very important for the residents to understand the system under which they work. Yesterday I asked Dr. Eric Davis, our medical student, soon to become resident, “Do you know what is a category 1, 2, 3, 4, 5, 6, 7 VA patient?” And, you know, he was able to relate to this. Then I asked him, “What’s a category A, B, and C VA patient?” You know, he was aware of it. But, we need to teach our residents about this, because some of those patients are having to make co-pays, and if we keep bringing them to our clinics, and they are making those co-pays, but we’re not thinking about it. We think that the VA is free and that they don’t have to make co-pays on their medications. The same thing with the patient that lives 200 miles away and is being referred to the VA from a community clinic. We are scheduling preoperative tests, a CT scan, a cardiology consult, and every time the patient has to drive 200

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miles. We are not taking advantage of the system, the patient can be housed in courtesy quarters, have all the tests arranged within one day, and now we are working to improve the delivery of health care. We are trying to understand the system and work within that system in order to improve the delivery of health care for the patients. Dr. Polk: What are we going to do with these 5000 points of lights focused on one poor little resident? Dr. Itani: I don’t think you need to do them. Dr. Polk: That’s a weight off your mind, isn’t it, Claude? Dr. Itani: Doctor Organ told me he did 3000 last night! You don’t need to do them. You just need to construct your goals and objectives and incorporate those within the goals and objectives. We had a template that we reviewed yesterday on how to incorporate those core competencies within the goals and objectives that we have within each program. If I have time later on, we’ll share that template with you. Then you build up your assessment tool based on those goals and objectives, and all that you have to do is have the faculty evaluate the residents, make sure that at the end of each rotation, you review the goals and objectives with the residents. At the end of the rotation, that you review your assessment and give the personal feedback to the resident, and then allow the resident to do the same thing for your faculty, and make sure that the faculty is aware of those evaluations. If you want to become a little bit more sophisticated, then you can start having some other health care input. At this point in time, at Baylor, we let the nurses give us some input about how the resident did in terms of interpersonal communication and professionalism. We went into various scenarios within our group on how this can be done. You can have patient surveys, but I think that this is in the very early embryonic phases. So we had a very good group discussion, and I’d like to share the template that we developed. Dr. Polk: Are there comments from you about the points Dr. Itani has made here? I mean, I think if you heard anything, changing the name of the M&M conference sounds smart. Dr. J. David Richardson (Louisville, KY): I didn’t hear anything about funding. Dr. Polk: For the efforts involved in this, where do you get some funding, because this is intense “person time” to make this work. Dr. Itani: Everything that you have here, you have it available in your Department. You are not going to do anything different than what you have, unless you do what Vanderbilt has done, and what we have done, which are the institutional lectures. Here in Louisville, the addiction program is an example [2]. So, we are tapping into local expertise. We are not spending money. At Baylor, we taped those conferences, and now they are available on videotapes. We are going to put them on the Baylor Web page, so that you can log in and view them at your convenience. Unidentified participant: Historically, we have had end points to measure. I’m not talking about the 2000 points, but

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I am talking about the intervention that we do, expecting it to be worthwhile. It is worthwhile to have some kind of evaluative process, and that is what we have not been doing, and that will cost some major resources. So we come back to if we are going to measure anything that we are doing. Where are we going to get the resources to evaluate that? Dr. Itani: You are going to collaborate with the GME office and the Dean’s office in order to get those resources. You will have to ask the Dean and the GME to come up with the funding, because it is not just your problem, it’s also the problem of the chairs of the departments of medicine and pediatrics, and anesthesia, and PM&R. They are all part of the same boat that you are in, and we all will have to have the help of the institution. The commercial Webbased program that we have purchased at Baylor is going to cost us $35,000 a year, so that’s not a lot of money, when the undergraduate school and the graduate school and all the graduate medical education is going to benefit from such a program. Dr. Polk: Sounds like, though, you’d have to sell it as a special project or it is just another unfunded mandate. Are there some other questions for Dr. Itani? Dr. William G. Cheadle (Louisville, KY): Just a comment on the six core competencies and system-based practice. It is going to be important to have a resident participate in each hospital’s quality assurance (QA), which is an affiliated hospital to your institution. This is a great way to show that you are involved in that process so they can run a particular system. It is something that we have done at our University Hospital but not at other hospitals. I think we all probably should do that. Dr. Itani: I completely agree with you and document it. Dr. John S. Spratt (Louisville, KY): I just think there are other core competencies you have to think about. First, I’m worried about outcomes. You’ve got to know some fundamentals of statistics and how to analyze the outcomes. The second thing is to know something about operations research techniques so you analyze the efficiency of your work and your work environment. You must realize that you don’t have to have multidisciplinary decisions for every process. It is very expensive, and it is always not the most efficient way to do things. Then I think the residents have to have some insight into medical economics. Exactly how they get that I don’t know, but it is not an integral part of most residencies. It is a necessary area of competency to cope with the system, and we are not doing a very good job in those areas. Dr. Itani: I agree with you, and as you can see from yesterday’s presentation, those are covered within the core competencies. You have to use evidence-based and statistical measures in order to deliver proper care to the patient. In economics, this is practice-based learning, how to deliver care in the most efficient way taking into consideration the resources that you have available to you. Dr. Organ: I think that this is going to be a hard sell if you are simultaneously talking about the quality of life of

residents. We have run out of time to allocate; we are at 120% of the residents’ time already. I think that to do this, this is going to have to be really defined functionally so it does not take up a lot of time. We can not do all these things, and I submit, when is the resident going to take care of patients in the clinic, in the operating room, and then give this any priority at all? I think that’s going to be the biggest thing you have to cover. Dr. Itani: I agree with you, and that’s reflected by the certified 50% attendance at those conferences. We have to make sure that we build it within the existing curriculum that we have, otherwise we are going to fail, and we’re going to extend the time rather than shorten it.

Workgroup II Strategies to accommodate changes in resident work environment Dr. Polk: Doctor Taylor is on the study group called Strategies to Accommodate Changes in the Resident Work Environment. While he gets set up, I want to note some discussion over dinner last night that was another common theme that has not yet fully surfaced in our discussions. When you talk about resident work environment, a lousy, inefficient, poor turnover in the OR is a big factor. There are a lot of things I expected to hear during the course of this conference, but that wasn’t one of them. Doctor Stoll, I might say that efficiency in the OR and its impact on residents’ morale might become something to kick off on an RRC visit form. There is a lot of sense to that, in terms of creating an environment that undermines or reinforces our regard for our residents. Dr. Rodney J. Taylor (Louisville, KY): I just wanted to go through our process. I wanted to thank the committee members: Doctor Grosfeld; Josh Neubauer, one of our senior students and soon-to-be-intern; Molly Poole; and Serge Martinez. We were charged with strategies to accommodate changes in resident work environment. The first thing we asked is what is wrong. We brainstormed through this and noted everything from personal time to safety and security to cleanliness. We combined everything into a smaller group of things we thought we could deal with that should be improved. The first one we chose, not necessarily in the order of prioritization, was improvement in personal time. These are some of the things that we think can be done: no Saturday conferences, do things to promote family activities, and directly encourage and improve family and personal time. Doctor Weaver talked to me this morning about a resident who just said if they could get one day off in the middle of the week, or some time off every 2 weeks, it would be an improvement. We looked at education prioritization. I don’t remember whose term that was to assure a balance between didactics and patient care. The faculty

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responsibility to assure resident conference attendance, that basically means that we have to realize the resident may be, as part of their education, required to attend a conference, and that may supersede a procedure. We must find ways to deal with that, with adequate support to help that occur. We must limit the amount of scut work, improve and develop a Web-based system for rounds and conferencing for somebody who misses one, have tech centers development, some of which is already developed but can be expanded on, as Dr. Grosfeld mentioned.

In terms of environment, improvement is needed in fringe benefits and perquisites, such as free and accessible parking, and some consideration for benefits of retirement accrual. Our residents are in their late 20s and into their 30s, essentially working at a slave labor level, when their peers have already begun to develop retirement accounts and investments. Insurance coverage for the family as well as for the individual could be improved, and helping with some family facilities within the medical center as well as on-call facilities. We are not necessarily advocating that everything look like a corporate box at the basketball arena, but one of the things that was mentioned was make sure that there is an available gender-specific, lounge type of area. A big point that was made was that food service be available literally 24 hours, so that people are not just getting the worst possible combination of food. I guess every night you’ve got a choice of onion rings and chicken fingers. The area should be comfortable, spacious, well-appointed, and conducive to rest and conducive to study. These are not terribly expensive, and they need to be done now. Safety and security speaks for itself. The institutions must be safe and secure. Some of these issues are potentially more pointed toward the women that are coming into surgery, but it extends to everyone. You cannot feel threatened any place in your working environment. We need to improve the defined educational process. We need to really define the goals and objectives, not just in RRC documentation, but the resident needs to see them, see them frequently, and needs to receive feedback, which is timely and confidential. Special things that we talked about is making sure that the residents early on get some training in how to teach and how to evaluate. We expect the residents to evaluate themselves, but we haven’t gone through

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that with them. We are expecting them to teach, but they are poorly prepared. We think that a mentor system, mentioned repeatedly, must be truly developed so that everybody has a known mentor. We need to develop accurate measures that are part of the overall issue and improvement in the overall environment. We titled abuse of authority as a rolldown issue. It starts at the top and rolls all the way to the bottom. Medical students are probably the last people that have anybody to abuse, but I suspect the “fourth years” abuse the “third years.” It is embedded in the system and adds a negative impact to the environment. We need to improve our awareness. We basically need to develop a zero tolerance policy with a fair grievance policy with no threat of retribution. Poor communication—we need to improve communication within the system and improve ways to obtain and provide patient information. Our hospital-based services need to improve the access to that equipment and their turnaround time. I learned a long time ago if you wanted to hide a person or a body in the hospital, put it on a gurney outside radiology, no one will check for a day. We need to foster an environment for better patient care and teaching and develop a true community of learning. We then hit inefficiency, especially in the operating room. My personal observation is that the operating room at our University Hospital has achieved perfection in inefficiency. There needs to be “truth in scheduling.” We need to adjust for surgeons’ estimation of their own operative time. Start time needs to mean start on time. These were things mentioned yesterday by Dr. Organ. We need to get the operating room back in our hands. It is an extremely frustrating thing for all of us, and destroys the residents’ morale. We need adequate secretarial support, a good electronic information system, and expansion of the ancillary personnel to help cover, which includes PAs. We also need to change the mind-set: “Well, you know, it’s 2:30 and we can’t start your case now because the people come on at 3:00 o’clock, and therefore you’re going to start at 4:00.” We mentioned environmental cleanliness. What you see is a perception of what you’re going to get. We need to make sure that within all of these environments that there is a visual appeal. That just means that our people are happy in what they’re doing. Inadequate number of house staff in terms of coverage result in people being torn in several different directions. We must realize that our primary goal is education. We’re going to have to find expanders to help with that, and that is going to require major financial support. The issue of ethnic and gender bias within the environment—we need to make sure that is eliminated. Finally, we wanted to mention finding ways to attract students much earlier in medical school into surgery, and exposing them to the joys of surgery. Some of the thoughts were development of some mini rotations that you can get first-year students at some time within the surgical discipline.

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Another issue of concern was the 20% dropout and improvement in retention. We felt it was part of the environmental issue, but it is somewhat separate. Dr. Polk: Rod, that’s unbelievable. Thank you for going through that with us. That last little point is real. There’s a dropout rate in surgical disciplines — the dropout rate in all medical disciplines is something on the order of 10% or 12% of people change their minds about what they are going to do after their first year. It’s a little higher in surgery, but not a huge thing. We do bring people in, and they do become disillusioned, but it is a loss rate that adds to our other problems. Could I encourage some comments or questions about Dr. Taylor’s presentation? Dr. Josh Neubauer (Louisville, KY): Yes. Basically, we understand that the reason for this Conference is to improve on many of these aspects of a resident’s life. Our aim was to look at these “satellite issues” that could make the work hour issue a little bit easier to focus on, such as convenient parking, food, the availability of families to come in and see the residents on call. As those outside issues become easier to deal with, the resident is going to focus his or her attention more easily on the work and be more efficient. Their life will be more efficient if the system can help them with those satellite issues. Dr. Robert H. Bower (Cincinnati, OH): Two issues that I think are worth talking about: the first is pager abuse. A few hospitals have come to systems whereby at night, nurses with questions are required to filter calls through a nursing supervisor before the resident is awakened. I wonder if we could hear some comments on that. The second one is protected time for educational conferences, but additional ideas for how to teach both the residents and the faculty that this is protected time. I’m impressed with how often, even when the resident brings up, “Doctor X, it’s 4:00 o’clock and we’re supposed to go to conference,” there’s the raised eyebrow, the rolled eye, the sigh, and they say, “Yeah, I suppose. Go ahead.” The resident gets a very clear message from that response that even though the person will tell the program director, “What are you talking about, I said go ahead . . .” Dr. Polk: “. . . I said go ahead, and I gave him a bad mark for lack of interest in clinical surgery.” Dr. Bower: The resident understands what the priority is from that. Dr. Polk: It is interesting that the conference attendance in all our programs is 35%. Of course, the unwritten word is that the 35% or 40% are those who least need to be at the conference. Dr. Organ: I’d like to make a plea with regard to physician assistants and nurse practitioners. I think once you bring in nurse practitioners, there is an administrative problem. There is the feeling that they are separate advocates for the patient and report to the nursing service. That is a headache that we don’t need. I’m kind of surprised you brought up the matter of the

disciplinary procedures, the appeal procedures, because I thought that was one of the things that the RRC reviewer really looked at to see that we all have an appeals mechanism that is fair to the resident, avoids the intimidation factor. I think most programs work very hard on that. Dr. Polk: I agree, Claude, that is probably a lesser issue. Talking to the younger people in the room who have never had any experience with it, there are pretty exact appeal processes and protections and due process for almost any complaint at any level. Among the things we’re presently doing, at least that’s in place. I don’t think anybody wants to promote frivolous complaints, but the process is decent. Dr. Taylor: I don’t think that we were talking about whether a process is there, but we were talking about having no fear of using it, and I think that’s the issue. We wanted to make this a much more open and friendly situation, where people are not intimidated. Protected time we did discuss, and it gets buried, but the issue of paging is overwhelming. Frankly, it is my pet peeve. Don’t have your wife or your spouse page you in the middle of the day for nothing. Your pager goes off enough. It is important to basically have pager prioritization. I think it’s a great suggestion that we work out a system whereby questions in the middle of the night, those nuisance questions, are diverted. Dr. Polk: That beeper abuse thing is mutual. Typically a resident asks to be paged with an absolutely meaningless lab result. You’re not going to do anything about it, but beep me the results. Dr. Stoll: There are two issues whenever we get into dealing with resident complaints that are critical. The first of which is many of the initial calls that I get from residents. By the way, that is a very large part of my job, talking to residents, and they fear retribution. So that is one issue. The second issue I encounter very frequently is, even though some sort of a grievance process is available, the residents that go through the grievance process frequently come out of it with the idea that it was rigged. That may or may not be correct, but I think that it’s one thing to have a policy, but the second thing is to make sure that it’s used correctly and appropriately and fairly for the residents. Dr. Polk: Doctor Larson. Dr. Gerald M. Larson (Louisville, KY): Yes. Rod, what was your discussion about making Saturday a rounding day only without conferences? If you take 2 hours off Saturday and move it somewhere in the week, you are really going into prime OR time and clinical duty time. So how did your panel address that? Dr. Taylor: We cannot run down to a situation where everybody’s off on Sunday or we start off days from 2:00 pm on Saturday to 2:00 pm on Sunday. That was a mentioned issue that we must get to a point where we reassess our priorities and clarify what our goals and objectives are. I know these are buzz phrases, but then we say, “Look, this has to be protected time,” because otherwise we’re not

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meeting the requirements, and we say we have to move it someplace. Dr. Stephanie Mayfield (Louisville, KY): Yes. I would like to comment on a few subjects concerning residents. I am the Associate Chief of Staff at the VA Medical Center in Louisville. In an attempt to increase objectivity and decrease fears of reprisal, evaluations of attending physicians by the residents will be housed in our office of education. The evaluation results will be reported to chiefs of service without the names of the residents. In July our residents will receive a guidebook to familiarize them with our medical center. Also, it is very important, that negative comments about other specialties from attending physicians be avoided. As a pathologist, I feel we must set a positive tone for the residents by promoting interdisciplinary cooperation beween specialties. Dr. Daniel Beauchamp (Nashville, TN): In relation to Dr. Larson’s comments, we have moved our grand rounds from Saturdays to Friday morning. We’ve tried to convince all of the surgical services to have their grand round activities during that period of time, from 7:00 to 8:00 a.m. Also, the nurses and the OR staff have their conference at that time as well. We just start Fridays at 8:00 o’clock rather than 7:30. We have our M&M conference on a different day. So it is possible to do it in the middle of the week, and I think most surgical programs are moving toward that across the country. I wanted to talk to the issue of OR efficiency. It is something I spend a lot of time thinking about as surgeon in chief of the hospital and chair of the OR committee. We have an information management system that we’ve incorporated into our ORs. We have started to actually look at the components that make the time that’s used in the OR. Some of it is case turnaround, I’ll give you that, but I can tell you that once you start looking at the data and digging into it, it’s like Pogo said, “We have met the enemy and he is us.” If you look at the factors that influence case length and contribute to inefficiencies in the OR, most of the time it is the surgeon and surgeon behavior. We have to be very careful about pointing fingers at other people and blaming them for inefficiencies in the OR. Dr. Organ: Doctor Beauchamp, could I ask you whether or not you think this is related to the intensity of supervision that these cases are prolonged, because the staff needs the room very early? Dr. Beauchamp: That is part of it. In some cases, where there’s gross inefficiency within a service, you may have a service or a surgeon that schedules two cases simultaneously. As the surgeon schedules two cases simultaneously, or even if they overlap moderately, that surgeon cannot be in both cases for the entire length of those cases. Or if the resident gets started, the surgeon comes in an hour later. You know that while only the resident is there and the staff, the anesthesiologist is not going to move as quickly in getting that patient to sleep, getting them positioned, prepped in the OR. Things just do not happen as efficiently

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if the surgeon is not there to get the case started and to get the case finished. Dr. Thomas R. Russell (Chicago, IL): This is why so much surgery now is moving out of the hospital, because surgeons realize that 80% of general surgery can be done in the outpatient setting. This is why a lot of surgeons are opening up their own operating rooms, so they don’t have to deal with the gross inefficiency and the waste of time. Dr. Beauchamp: But I can bet you if they open up their own centers, they are going to be at the case from the time the patient enters the room until the time the patient leaves the room. Dr. Polk: There’s also a wonderful saying behind those centers that made them successful. There’s no 3:00 to 11:00 shift for nurses. You work until you get through, and you can’t go pick up your child from the child care or you can’t go grocery shopping, you can’t reach your wife, or whatever, until you’re out the door. Dr. Beauchamp: There’s a big difference in those types of cases, which are very predictable. You don’t have patients that are extremely ill. They are not going to stay in the hospital, where you have a hospital that has to take all comers. There’s a big difference. Dr. Organ: Dr. Polk, why do you and Dr. Taylor feel our conferences are characterized so persistently as being boring? I know they are, but I want to know the reasons why, because my concept is, I think we give very little attention to mapping these conferences out, giving attention to the text of them and the breadth of them.

Dr. Taylor: My opinion is that, to a large degree, we forget who we are educating—ie, adults—and adult education principles are dramatically different. One of the things in an environment like this that keeps people alert and active is participating. Conferences that involve somebody putting up slides in a dark room is narcolepsy defined. I think that we need to understand that adult education works best when it is participatory and that the kind of conferences we have are best when it works that way as much as we can. There is a role for lectures and

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conferencing, but let us keep in mind that there’s a limit to what people can tolerate. Dr. Polk: I think the worst thing about that is the speaker who takes no interest in who the listener is. He is playing to himself and another object and makes no effort to reach to the potential listener.

Workgroup III Addressing the financial consequences Dr. Polk: The next subject that we have is one of the most vexing. If we make some of these changes that are likely to occur, the financial consequences of those changes will be huge. They impact on us as faculty, but certainly on our main teaching hospitals. Our speaker is Mr. Bob Barbier, who is the chief financial officer at the University of Louisville Hospital and has prior experience in Houston and in Atlanta with major teaching hospitals. Mr. Robert Barbier (Louisville, KY): We are only talking about money here. Our group started off thinking about some type of quantification of what does this change in the cap on hours per week? According to a survey we had done at our hospital 2 years ago, the responses we got seemed to indicate that the residents were working about 100 hours a week, so going from 100 to 80 represented about a 20% drop in those hours of availability, which for us, according to the FTEs of residents, that would represent a change of five. So what do we do with five residents? What kind of void would that create? Would we be able to fill it with either more residents, more faculty, or some type of extenders? Any of those solution sets indicate an incremental cost.

We also want to note that many of the surgery residency programs take place at some type of public hospital location. Throughout the country, these are typically publicly underfunded locations. The revenue is inelastic and, of course, the hospital is poorly utilized by the Medicare cov-

ered patient. Also, these hospitals typically have trauma services that require 24/7 demands that patients are to be seen in those locations. Ultimately, we figured that the significant cost increases that come from changing the amount of time residents can be in the hospital cannot be met in those facilities and might put some other service in jeopardy. Now, if this wasn’t scary enough, my partner in moderation, Ron Greenberg, then went into a long discussion about the suit that was filed earlier in the week in terms of an antitrust action regarding the resident matching program and its implications. There’s going to be a lot more to come on that one. Doing some quick math on what we think is going on, there are some 200,000 residents or former residents that are said to be engaged in this action; if, in fact, the challenge says that the residents weren’t paid enough due to antitrust collusion among academic facilities and the matching program. If the true wage or the agreed-upon wage is $100,000, we are talking about billions of dollars in potential damages, and being filed under an antitrust statute, there is also the ability to get treble damages. Now, I don’t think any hospital has any reserves for this type of thing. Doctor Polk was quick enough to observe that this would represent a “double whammie” for hospitals, in that we have fewer hours and we’re going to have to pay them more. I’m letting that sink in. Also, the hour restriction would eliminate or greatly restrict the hospital’s ability to cover some services through a moonlighting function, since the moonlighting hours are added to the hours worked on a weekly basis. I know we do use some moonlighting physicians throughout our facility here. We just went down one path very quickly—that perhaps there would be a reciprocal raising of the cap that was instituted under the BBA 97, and we would just end up with more residents to cover all of these things. But that quickly led to a discussion of, if we did that, we’d be on a track to creating more specialists, and there’s been some hesitancy in the funding from Washington as to whether or not they really want to create an increasing trend of producing specialists.

Dr. Polk: I guess that is probably a nonstarter, the idea that if we had a 25% reduction in work hours, we’d add 25% more residents and finish a large number of people. I don’t

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think that is ethical and I do not think it is a tenable strategy. Well, bad things do happen. Just because they’re bad doesn’t mean they won’t happen. Mr. Barbier: We did have somebody mention that this might provide an opening for the osteopathic area to try to create its own surgery programs. We didn’t go very far with that, but it was mentioned. Dr. Polk: Let’s suppose that we need some more, in Kentucky, and we finish 7; the University of Kentucky finishes 4 for a total of 11. You give us some more, and the real politics here might well look at that as a resource for the new osteopathic school that has just started in Eastern Kentucky. If somebody was going to have any political clout about it, we might not be politically eligible for that and it would be a program that is not yet educationally favorable. So the politics of this decision to look at raising the number of residents is a multi-edged sword. Mr. Barbier: With fewer residents available during the week, should we think about positioning them at different times on service? The specific example was in trauma. If we really think the coverage needs to begin more in the afternoon and the evening cycle, then maybe we stage it that way or use some type of nurse practitioner or extender during the day, or other folks that are around on the daytime shift. Perhaps there may be a somewhat lighter volume going on there. Then, of course, that led to a discussion about whether we have an increased demand for nurse practitioners, what does that do to our nursing shortage? It was not positive. We had a discussion about residents in many hospitals— or in some hospitals residents are the hospital. The comment is that residents have been taking up the slack in some hospitals in covering for poorly-performing hospital staff. In other words, doing things well beyond what a surgeon in training ought to be doing. If, in fact, we have a reduced amount of residents there, that there could be an increase for sentinel events to happen or basically adjust the risk profile of the hospital in a very negative direction. Considering this from a public hospital perspective, you get into all the malpractice issues, the continuation of those types of costs. Ultimately, down in some never, never land, there may be some possibility for tort reform, but again, that’s out on an extreme. Then there was a comment related to the fact that the RRC is, in fact, tightening up; at least that’s what Yale-New Haven found out. They have now had their residency accreditation withdrawn, although there is time for them to correct that, before it actually gets to that effective date. The last comment that Dr. Martinez brought up is that there is definitely a trend and an observable situation where fewer of the graduating residents are choosing to go into academic medicine. This will ultimately limit the number of faculty that are available to supervise what residents we do have in the future. The takeaways from our group yesterday are there. No one in the group, during the couple hours we talked, had any suggestion that there was any way to reduce demand for

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surgical services. So we expect what we’re doing now, there’s just going to be more of it in the future. I think that no matter what happens, there’s going to be an incremental cost to the hospital to deal with this. There will be an increase in demand for some type of surgery — or surgeon extender. It’s totally unclear as to what the change will be in the risk profile of the hospital providers when this happens, with the possible impact on the cost of malpractice coverage, and the ultimate ripple effect is going to be long-term availability for surgery faculty. That was our group. Dr. Polk: A tough issue. Dr. Wm. Lynn Weaver (Atlanta, GA): The key question is what all these changes are going to cost. Where is this money going to come from? Did your group discuss where this money would come from to fund this idea? Unless the federal government drops a couple of trillion dollars on us, how is this going to happen? You know the type of hospital that my program is in. Mr. Barbier: Yes, sir. Dr. Weaver: Which is always millions in debt. Mr. Barbier: There just wasn’t any ray of sunshine on that angle. I think, for the most part, the folks in the room were trying to deal with the immediate issue of how do you provide patient care which is appropriate. Perhaps there will be strategies that evolve, either the scheduling or using any type of an extender as a somewhat intermediate cost step. There may be some efficiencies that come out of a change in the scheduling that ultimately move patients through quicker. That was not touched on. Maybe we can mitigate some of the potential incremental costs by just through-put type improvements. There has been a lot of commentary in the early part of the day about inefficiencies in the OR. There may be other things involved in the whole delivery of surgical care that can be addressed, which ultimately, from a different point of view, help us. In terms of finding buckets of money, I don’t know of any out there. I know the upper payment limit transactions periodically do give us a little boost, but those go away rather quickly. Dr. Polk: Dick, do any other federal bills involve any potential support for these plans or are they all unfunded mandates? Dr. Richard Knapp (Washington, DC): There are two bills, one in the Senate and one in the House, for all-payer financing of graduate medical education, but they are effectively dead. They were all Democratic sponsored, and they are basically viewed as a premium tax. We keep supporting, and we push them, but it’s an uphill battle. Dr. Richardson: Is there any awareness on the part of the University Hospital administration at this hospital, of the tremendous inequity in terms of workload between different resident services. Most other services have very different schedules and patterns of providing patient care. Unidentified participant: They generally have shift coverage at night, so they only work just part of the night.

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It’s not even just an 8:00 p.m. to 8:00 a.m., but they take admissions until 2:00 a.m. Dr. Richardson: Many physicians don’t want to take care of any sick patients if there’s any possible way they can make a surgical problem out of the patients’ situation. Most could not start an IV if their life depended on it. What I’m quite amazed at is that we as surgical faculty often let our trainees be abused by other specialties. Then other specialists use this differing level of commitment to patient care as a recruiting tool against surgery by saying, “Look how hard the surgical residents have to work and how easy we’ve got it. Not only that, you can go moonlight and make a lot more money and pay your educational debt down. You certainly can’t do that if you go into surgery.” Do you in medical school and hospital administration have that on your radar screen? Mr. Barbier: As much as I would like to help with that issue, I think it is a physician-to-physician discussion. Dr. Beauchamp: I just did a quick back-of-the-envelope calculation. If you have 50 residents and you decrease them by 0.2 FTE per resident, then you need about 10 to replace that effort, or you need 20 nurse or PA FTE equivalents at a 40-hour work week for those professionals. So if you have to pay the nurses at about an average of $75,000 a year plus fringe benefits, that’s about $1.9 million per year for just getting replacement hours for 10 residents. If you are going to replace them with 10 residents, that’s about $567,000 per, across the country. We cannot get more residents unless you extend the number of years of residency or you dramatically change the way that we train residents. Dr. Organ: I’m not sure your initial premise is correct. Will you read that again for us, as a conclusion, Mr. Barbier? Mr. Barbier: My first take-away, and this is mine— there was no discussion of a change in the demand for surgical services as we currently know them. If you’d like to jump on it, I’d appreciate it, but that didn’t come up and nobody seemed to see that as part of the solution. Dr. Organ: I think there are a lot of elective things that could get lower priority until we get this under control. I am not too sure, you know, how to list them, as tonsillectomy, bariatric surgery, and some of the cosmetic things of the face. I’d like to see a review of all of these elective things, but I think, as I told Hiram this morning, it’s immoral to have the best in American surgery waiting, with anesthetists, nurses, and operating room, for the dregs of our society to get involved in a lot of penetrating trauma. Dr. Polk: I don’t agree with our honored guest. I think that the balance of surgical training is absolutely critical. It’s been unbalanced, true, but then you have an unbalanced trainee! We have a lot of broad experience, which is a trauma center, the VA, elective and nonelective, and that broadened the base for quality training. The overwhelming demands of the emergency service sure ended up with some unbalanced trainees. Unidentified participant: Well, I wanted to go back and

just challenge the response to Dr. Richardson’s question. The implication, if I understood you correctly, is that the hospital does not have the ability to influence the allocation of dollars for X number of specialty residents or nonspecialty residents. Could you help me understand that a little bit better, why do you feel this has to be a physician-tophysician issue? Mr. Barbier: I believe the question being raised was why are medicine people only taking care of two folks a day and not admitting folks to the ICU after 2:00 o’clock? Now you’re taking that to a more global perspective. Dr. Richardson: That’s where I was trying to take it, honestly. Mr. Barbier: Back to the money—it needs to be a collaborative effort. Obviously, in our case, we’re closely affiliated to the medical school, and any dollars that are allocated are by the Dean. Unidentified participant: But do not the dollars flow to the hospital instead of to the college, in terms of medical education? Mr. Barbier: Initially. Unidentified participant: Then you should have some opportunity to reallocate those dollars. Mr. Barbier: Please understand, the governance of our institution ultimately resides with the Dean. Now, we have some ability to talk at the table and discuss and quantify things and make suggestions. There has to be a collaborative effort in this type of academic environment to deal with the allocation of monies, like programmatic things are going to be emphasized. Are we paying money for this physician versus that? Specific logistics of patient allocation and distribution throughout the day in our hospital is pretty much at a physician level. Unidentified participant: But I don’t think I would be surprised in that collaborative effort that the hospital would be requesting the college to pick up the tab on physician extenders, if it is a collaborative nature. Mr. Barbier: It is a collaborative effort with one bank account coming out of the hospital paying for these things. If we’re paying for nurse extenders, it’s ultimately that I’m writing a check, so that’s not going to help this conference out too much. I’m sorry. Dr. Polk: I just want to tell you again what a sobering report we received from Britain, which is probably 7 or 8 years into this process, and how the net effect of the thing is that doctors don’t work, people don’t get care, and leaders don’t make substitute adjustments, because they don’t have money to pay for anything. They turn out doctors who are not nearly so well trained as you had turned out before. Dr. Spratt: It strikes me that we haven’t considered enough the trial lawyers’ attack on the resident matching program. My concern is that this is so significant that it’s going to require us to rethink our entire medical education system. We may have to go more to a European model, where medical school then becomes 6 to 8 years, with the last couple of years being intensively clinical, and to re-

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model the entire premedical education system, which, from my perspective, doesn’t prepare people for anything. If they don’t get in medical school, they have wasted 3 years of college. Then they should move directly from medical school into what the Europeans call a Registrar system, and directly into your area of specialization. I’m just throwing this out for thought because it strikes me as a real threat to the entire contemporary medical education system. Dr. Polk: We’ve just got to be careful, though. We started out yesterday talking about surgery not being popular. Let us all go back and realize, right now as a whole, medicine’s not very popular. We have to be very careful about making changes in our medical system. It might be misperceived by college students as: “Wow, this thing has gotten longer and harder.” So we are at one end of the chain being concerned about our flow of applicants. I think any intelligent Dean has to be concerned about the flow of applicants to his School. Dr. Spratt: Part of the correction of that is to look at a larger manpower pool for applicants by doing away with the premedical education requirements and opening the doors of medical schools to anybody with a hard major. The MCAT testing system is an absolute waste of time. There are no data that show that any form of testing system predicts future performance. The only thing that predicts future performance is past performance. If you allowed people to come into medicine, not through the traditional premedical system, but with hard majors in various fields, such as statistics, computer sciences, economics, psychology, you would first of all enrich medicine, instead of stereotyping as it is at present. I do believe that this is going to have a ripple effect that is far broader than we are presently contemplating. Dr. Polk: A lot of what Dr. Spratt says is true, and we probably should focus on the morning’s project. I think Dr. Richardson, as the longest serving members of the admissions committee, we hit a nadir 8 or 10 years ago, and clearly admitted some kids to the University of Louisville School of Medicine who could not do the work. I just want to say that the open admission project, what Dr. Spratt’s talking about there, really does create a problem, because putting somebody through an expensive year or two of medicine to find out that this is something intellectually they cannot do is really an expensive policy. Bob, any closing comment? Mr. Barbier: It’ll be a collaborative effort. Dr. Taylor: My only comment is to add to what David said. If, within a system of paying for residents, we are having a problem meeting a potential hour restriction, and we have other people that we are dramatically underserving, I think that that’s an issue that we could deal with without adding anything to cost, but adding to education of the underworked. I find nobody in private practice who’s an internist who is not willing to come in and write orders on the surgical patients. They don’t follow them in the training program, and that’s something we ought to discuss.

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Dr. Richardson: I believe hospitals have a responsibility to accumulate data on differing levels of work between specialties. I understand that would be a difficult issue and ultimately would be a doctor-to-doctor matter, but unless hospitals put their weight and budgetary might on the table, nothing’s going to happen, and it will be business as usual. Dr. Polk: Let’s assume that some of the numbers you’ve got are inflated about those work hours. You are looking at paying the same amount of money to a resident that works 50 hours a week as you do to another resident that works 80 hours a week in your hospital. We need to talk about that somewhere. Yesterday you said the sense was there were enormous risks to beginning to stratify and do anything different within classes of house officers. We are already enormously discriminating against our young surgical people by having them work a lot more time for the equal amount of money. Dr. Weaver: I’d like to ask Dr. Stoll how it’s possible that we’re paying medicine, which gets away with how they do things, in that the medical residents receive the same amount as the surgical residents, but there are a lot more medical residents than surgical residents in most programs. Is there a consideration from the RRC or has it been thought about that we increase the number of surgical residents to do the same amount of work. Right now, as we all know, our programs are restricted by the RRC in the number of residents we can have. Remember, historically, medicine and medical specialties have never been very restricted as to ultimate numbers. Dr. Stoll: The RRC doesn’t look at it the same way you do. You are looking at getting a certain number of bodies here to do an amount of work. When the RRC evaluates whether or not a program ought to have or wants more residents, the issue really relates to the quality of the education that’s given, and specifically looks at the operative experience, number of faculty conferences and the like, and the breadth of experience that is available.

The RRC would never give a program more residents simply to have hot bodies complete all the work that’s available in the OR. They are concerned that the residents that graduate get the breadth of experience from entry to

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middle to upper level, and if there’s not enough upper-level cases, they will not increase the number of residents. If you’re looking at it from the RRC’s perspective, it’s not a work issue, not a service issue, but an educational issue. Dr. Weaver: Thinking outside of the box, are we thinking about changing the environment that we are in? If we can decrease the work hours by increasing the number of residents and still accomplish that primary goal of education, then we would still have the same end product. It would still be the same end product without all the mess in between. Dr. Polk: Doctor Weaver, the one place where that falls apart is the New York analogy. You start to make a very good point. We must have enough chief cases at the end to get somebody out the pipeline. That is what happened. Remember New York had the huge numbers of PG-1s and 2s that are going nowhere, and they had no place to go through the system. That doesn’t help anybody, actually. It even turned out to be one thing that “bit them in the rear” in the long run. It’s the high-quality cases that are going to determine those numbers. Now, there may be some other factors involved in that, but that makes that a harder solution.

Workgroup IV Reasserting the attractiveness of surgical careers Dr. Polk: Dr Russell, you’re going to report on reasserting the attractiveness of surgical careers. Thank you. Dr. Russell: I tried to get everybody involved here. I’d like to see a raise of hands, if I could, of those of you who are surgeons who would do it again if you had your choice to go back into your being 25 years of age. (Most participants raised hands.) Who wouldn’t do it? Who would choose another aspect of medicine or not go into medicine? (No hands raised.) I think that fulfills our charge about reasserting the attractiveness of the surgical specialties. I want to thank the people that served on our committee. We had a nice balance: John Draus, as a senior medical student; Bob Cacchione; Nicole Stassen; Lynn Weaver; Claude Organ; as well as Toni Ganzel and myself. This is really a dynamic time for change in surgical training, and I remind myself that the father of surgical education died in 1922. That is when Halsted died. Yet, we really hold on to a lot of the principles that Halsted espoused. We no longer have the pyramidal residency system where one man is at the top, fortunately. We have given that up, but still a lot of princes of the Halstedian system are with us today, and that is what this report that we have come forward with is about. We have broken it down into four parts: What is attractive about surgery? How to share those joys. What is unattractive about surgery? What can we do about these unattractive features?

Let me just go through some of these points. First of all, the satisfaction in surgery, of taking a really sick patient from the trauma bay or from a chronic illness and operating on them and restoring them to a productive life of quality is something that is incredible. Yet, this is where we really fall down in exposure with our medical students, that this is the life of the surgeon, what I call the broader spectrum of subjects. The opportunity to positively impact the lives of patients was really beautifully demonstrated by John Draus yesterday. He mentioned that when his father, who was a successful surgeon in Kentucky, died, so many of the patients that he had taken care of came to the funeral. They told John what a real influence and difference that his father had made in their lives. All of us have experienced that as surgeons. I have been out of practice for 2 and a half years, and I still get notes from happy patients. Some other issues—providing comprehensive patient care; providing continuity of patient care; experiencing the champagne of medicine, which means that we think we are about the top of the line, not sparkling white wine, but champagne; and serving as an advisor or role model or mentor for students and residents. Practicing high-tech, high-touch medicine—somewhere certainly you still have to touch patients and have an intimate relationship with patients. Offering this is another important point. The last one is offering a variety of options to students with regard to surgery. In other words, we do not all have to be surgical intensivists or we don’t all have to be trauma surgeons or transplant surgeons. It is possible to split a practice and have a practice that begins at 8:00 in the morning and can maybe terminate at 4:00 o’clock in the afternoon. I give as an example, many surgeons, men and women, who are now going into breast surgery, which controls their life. It is an exciting field. There’s lots of change in technology, really fueling much of the change. I do not think that we have often articulated very well to our trainees this spectrum of a surgical career. How to share these joys? I think we have really fallen down on this and, in my new job, I no longer get calls from patients who are unhappy or have a problem. I do get calls from Fellows of the American College of Surgeons who are unhappy with their practice. To be very frank, some of them should get out of surgery and shouldn’t keep practicing because their mind is tainted and they are so unhappy with the profession. We have to make certain that those people do not have exposure to medical students, but we do not have control of that. We have to articulate a positive message with clarity and at every opportunity, such as in the OR, bedside, conferences, clinical clubs for students. I was just thinking on the way over here, I am going to get on an airplane in a couple of hours. Suppose the pilot said when meeting all the customers coming aboard the plane: “I don’t suggest you take this flight today because it had a really tough landing and I haven’t flown for a couple months.” “I have all these prob-

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lems.” “I’m being sued about an accident that I had a while back.” I would not get on that flight. A lot of what I’m hearing from some of the surgeons is they’re really emphasizing liability, reimbursement, and it just doesn’t play well in Peoria to the young people that are thinking about a career in surgery. Let the students see you as a person. Take a personal interest in the students. Emphasize that the life of a surgeon isn’t the life of a resident, but the life of a resident is important to get to where you want to be as a practicing surgeon. Disconnect the malpractice and declining reimbursement discussion from the students. Stop the whining and stop the complaining about things. Engage the students in their first- and second-year through doing things like clinical correlations, participating in physiology and anatomy teaching, developing strong surgery clinical clubs, offering research experiences and advising and mentoring. These are some of the positive things that we need to do in those first few formative years of medical school. We need to keep the students engaged. What is unattractive about surgery? Well, we have heard a lot about sentinel events, but there’s another type of event called a behavioral sentinel event. This is when the surgeon who loses it in the operating room or loses it on the ward. That is totally unacceptable, and yet we’re still exposing our students and our residents to some of these behavioral events. Many of you are chairmen of, or heads of, departments and you must deal with these sorts of behavioral problems. Another unattractive thing about surgery to some of the younger people that are looking at surgery as a career is that it does involve some sacrifice with family and personal relationships and eats away at this quality of life. We should not participate in bad PR by disparaging other specialties. I’d like to pick up on the pathologist in the back of the room. My wife is also a pathologist, and I couldn’t agree more with your comments. This gets into the communication aspects of the competency. We have to stop bashing other specialties. We need to realize that not everybody thinks that surgery is the top of the heap. We must not fall victim to hubris where we’re holier than anyone else and we’ve got a great job. We must respect other people in the profession. I’m embarrassed at some of the things I did when I was a resident. We need to have good communication skills and respect for other disciplines. Saturday conferences should be put away. It was wonderful in previous years, but that really eats away at this free time. How do we address these issues? How are we going to change some of these unattractive aspects of surgery? We should delineate expected behaviors of junior faculty, and even senior faculty, and residents. Identification of the responsibilities of the Chair and the hospital executive committees to intervene with these aberrant behavioral activities is suggested. Another is to respect and validate family and personal

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time. We can cross cover for one another and create a family-friendly culture and environment. There is nothing wrong with not being here today because you have a family obligation. In the past, we have not recognized this as being important; in the future it is going to be key! We need to be respectful of other things because they are just as important as being in the hospital. The 80 hours is an issue. It’s probably reasonable, but we think that locking into a specific number of hours is probably the wrong way to go because it sends bad messages to the trainees. We can demand institutional support for physician extenders. Many of us have mentioned the same thing. Improve the efficiency and quality improvement initiatives to free up residents for time off and protected educational time. The next item is really key as we go into the future and time of change, which is to develop really good curriculum so that much of what trainees need to learn can be done in the hospital. We can develop a team approach to continuity rather than an individual approach. Certainly this is one of the paradigm shifts that we are experiencing right now, from the individual to the team concept. If it is done right, we can have continuity of care and get away from some of the problems of turning the patient over, which others have talked about. The team is absolutely key because the people that we’re training now do not want to spend their whole lives in hospitals. I have asked a couple of friends of mine who were older what their regret was in a surgical career, and many of them say, “I spent too much time in the hospital.” The young people don’t want to do that. They have an opportunity to change that, and we have an opportunity to help them with that. We can educate nurses and develop incentives and consequences for appropriate and inappropriate use or abuse of residents’ time. Don’t beat up on other services and other members of the health care team. Carve out protected time and put in mechanisms to monitor compliance with standards. Well, I simply summarize by saying that we have a great profession and we have great opportunities. It’s a changing time. Our job, our challenge is to articulate this for the future generation. Dr. Polk: I’ll ask Dr. Frank Miller, because he’s been part of something that really I doubted in my heart would ever work, which is the team continuity of care. We have some trauma services that are very busy, care for sick people, and do some big cases. About 2 years ago, we let the other team occasionally operate, when it was on their off day duty, on the other team’s patients. I must say that really bothered me a lot then. There have been a few little things fall between the cracks, but there have been a few patients, by getting a different set of eyes look at them, who may actually have benefited by having another team do that.

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Dr. Frank B. Miller (Louisville, KY): Well, what we tried to do was 24 on and so-called 24 off. When you were off, you still had a lot of work to do and you had to see all your patients, but many of them came in at 3:00 or 4:00 in the morning, or maybe came in 8:00 o’clock at night. By the time you realized they needed an operation, you had the team there much later. The fact that you could switch those patients from team to team, in the long run, it would work out the same in terms of the cases a resident did. You’d give up one, but you’d get one from the other team. In actuality, it really depends on the residents. Some do a pretty good job with it and some still don’t like the concept. What they’ve done most of the time is send the rest of the members of their team home so they at least get the other team members out (the juniors and even the medical student) but the chief will often stay. It has worked out well, and some do it very, very well, and others never do it. They still are there later in the afternoon. Personally, I think from a patient care point of view, as long as you have good communication and good cooperation—ie, both of the chiefs know the patient—it’s worked out fine from a patient care point of view. Dr. Polk: I absolutely thought it was an impending disaster, and it has been good to excellent. Doctor Russell said the idea is a team providing continuity of care, and it’s really been okay. John Draus, any comment on your part? Mr. John Draus (Louisville, KY): I was impressed with how receptive the members of the committee were, and it was a pleasure for me to be able to participate. It is nice to see the interest and enthusiasm of everyone. Dr. Celia Chao (Louisville, KY): I do not really have any answers, but it strikes me that this has become a circular argument. I do not really have any solutions, but I wondered if anyone has thought about the reason why people do not want to go into surgery— or medicine in general— or why there’s this class action suit. The reason is precisely because of long hours and not being compensated for the amount of work that is done or for the amount of education and the debt that they incur to reach that far in their careers. As a result, when student hours are cut back with the surgical services, the residents pick up the slack. When residents have their work hours reduced, attendings pick up the slack. The attendings grumble, and these comments trickle down to the residents and students, and it just becomes this huge circular argument. Dr. Bower: I would take this just a little bit further. I’m impressed, just as we’ve agreed that many of our faculty don’t understand the competencies in order to integrate these into the curriculum, many of our faculty think that I have personally invented the concept of reduced resident work hours and improved resident environment. There tends to be, in times of frustration, the idea that the residents aren’t as tough as they once were or that they’re whiners. The possibilities for fractious behavior within our own surgical family become increasingly important. The idea that we need to treat each other as colleagues and to be a little

gentle with each other at times and to understand that these periods of change are unsettling to everyone and to keep the spirit up within the resident-faculty relationship is very important. Dr. Spratt: I want to expand on Dr. Russell’s comment about personal behavior. Halsted had a contemporary named Osler, and Osler wrote a book called Aequanimitas. One thing you have to remember dealing with patients and other groups is the maintenance of equanimity, or once you lose your cool, you lose your effectiveness. This, unfortunately, is a bad habit for many doctors and it compromises your effectiveness. In fact, it increases your ineffectiveness because nobody pays any attention to you. Maintaining an “aequanimitas,” as Osler called it, is a very important behavioral concept that needs to be threaded into the entire profession.

Workgroup V Shortening the core residencies for surgical superspecialties Dr. Polk: Doctor Stoll has been asked to deal with something we’ve not mentioned in this room, but it’s a huge megatrend going on in surgery right now, which may impact a lot of these issues. It is the decision of several surgical superspecialties to shorten significantly the amount of time their proteges are going to have in general surgery before they branch off into plastic or thoracic. You can see this occurring on and on. I said, “Well, now plastic surgery is trying to make itself more like ENT. The faster you can, the better.” These changes are occurring, and they eat into our workforce and career satisfaction. They are also a threat, because the core of training that practicing surgeons in plastic and thoracic have always had, which were identical to ours, are now going to be fragmented and shorter and smaller. It is a major work issue if we were not dealing even with these other factors. Dr. Stoll: Yes. I think we had a really hot topic, and I doubt that we had enough time to even consider all of the issues. I probably knew a little more about it than the other members of my group, simply because I had the advantage of working for several years with plastic surgery as they made curricular changes. I am now working with thoracic surgery. The minute I walked in the door, they said, “We’re so glad to see you because you did this for plastic; now you can help us with thoracic.” Basically, the issue relates around several meetings that have been held quite recently, the last of which was this past January. APDS and the Council of Thoracic Surgeons met, and I reviewed minutes from these discussions. The premise that came forward was what can we do to shorten the core training in general surgery from the curricular perspective that will permit individuals to go into the

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various specialty areas a little quicker—i.e., complete training in a shorter period of time. So we called our discussion group: “Are 5 years of general surgery training really necessary?” I will tell you that it was a touchy group to manage because everyone in the group did not agree that this would be a good way to go with education.

I’m going to insert some of my personal preferences in here, and you can argue with me later. I will tell you, as having come back to surgery after having been out of the OR for a long time and forgetting what was going on with general surgeons, I was surprised to see, as I read through all of your curricula, how much wasted time there might be or how much pressure there is now on you to put in so much service. We talked about such issues as the real need to have a competent individual graduate that is ready to cut and sew and to handle all kinds of situations at entry level. The second thing was to at least explore how we could make the curriculum more efficient, cut out some of the wasted time, and focus more on some of these other issues. I was glad to hear the question that came up earlier on financial issues. The focus was from different people about how you look at what a residency training program is. From our perspective, it is education, and one of our buzzwords across all of the specialties in ACGME is there must to be some balance to the service along with the education that’s offered. There are far too many programs where that balance is really out of whack, and that’s frequently cited for programs. Here is our discussion, and we hope that you take some of this information home and think about it. If you have any final comments, I would like to hear them. The RRC is going to have a retreat the end of June where they have invited some of the leaders in the field into the meeting. We are going to again discuss this issue, because as you understand, it’s not only an RRC issue, it is also a Board issue, a specialty issue, a program director issue, and it is a College issue. All of the players have to agree in some respect about how this can be accomplished. Here are some ideas. It may be desirable to achieve the competent surgeon in four years, based on all of the factors — social, financial, political, and the like. There was no support from our group for deleting the chief year and, in some of the documentation, it appeared that was where

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others were going. We did not agree with that premise at all. Some of our discussion was based on our experiences in dealing with the change in plastic surgery to an integrated 5or 6-year program. One of the criticisms of that change for plastic surgery was that the plastic surgery program directors as well as chiefs of surgery felt that the degree of maturity and stability and authority that the chief needs to get from that year. That maturity piece has to be there for every surgeon, whether they go on to superspecialty or not. So there was no support for that. Instead, we suggested that the years one and two might be compressed, which is where the issue of efficiency comes in. In order to look at how this compression could occur, we must sit down and begin to look at what are the goals, if you choose to use that word. What are the competencies that you really want that graduate to have at the end of the 4-year program? Pick and choose among all of the things that you’re currently doing and prioritize them. We also agreed that, in order to compress this curriculum, it is very dependent upon improving the systems that we’re working in and the efficiency of the rotations right now. There must be more learning and less service. We also agree that there were certain skills or assignments that may be able to be either deleted or decreased. So we get into this whole issue of competencies. How many cases are enough? Do you have to do 200? How many times do you have to do it until you really know how to do it well? So that also is a major issue whenever you talk about changing a curriculum. We also spoke about the consideration for increasing the time medical students spend in surgical activities to try to make the transition from medical school to the PG-1 year more seamless. Another qualification that we agreed upon was that it was still desirable to have multiple pathways to superspecialties. This will require close working relationships with general surgery. A theme of our discussion throughout was that perhaps when plastic surgery went out and changed their curriculum, and they came back to their chiefs of surgery, what they were trying to do was cherry pick the good experiences for the plastic surgeons and leave all the scut or the garbage for the general surgical trainees. In this particular instance, there’s general and global agreement across the department and with the specialties to keep these communication and good relationships going. Lastly, our caution to the group was, as we explore this particular avenue, changes in residency education must ensure that the competence of residents is maintained, and that safe patient care is also the priority, as opposed to selfserving criteria. Don’t let these pressures for money distort what is good for the specialty. Dr. Taylor: One of the questions that came to my mind when you were proposing this was if you demonstrate that you can improve the efficiency and train in 4 years, why should the federal government support pay for 5? Dr. Stoll: We didn’t explore that issue, I’ll be very frank

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with you. It would be interesting to see what the Feds might say. Right now, the law says the first 5 years or the first certificate. That part of the discussion relates, at least in this venue, to the need for certain surgical specialties to really increase the length of their training time because of the growth in technology. So we ask will that require some federal change? Probably. Dr. Polk: There was a brief experiment conducted by the American Board of Surgery in the late 1970s with permitting selected trainees and selected programs to finish in 4 years. The overall impact of that, any way you read it, was that they were about 80% as well trained as the 5-year people. So, you know, yes, you can do it, in the same format, we just took the middle year out and let them go on and be chief. So just shortening the time, you get what you would expect. One of the issues that everybody’s walked away from was that there is no funding for the massive amount of time faculty are going to have to spend on this deal. I cannot tell you how many hours Bill Cheadle has worked for not a nickel in trying to take some of our program and get it up to cutting edge on competencies. I mean zero. These things are not cheap. This is hard sweat, hard work stuff. The trouble that just bothers me over and over again is that there is no relief, no reimbursement, no help for what’s an enormous intellectual and organizational problem.

Dr. Organ: In discussing this scenario—was there any attention given to the need for, or the persistence of, double boarding? Dr. Stoll: Yes. I would say to you that there are some specialties that have simply made a decision that double boarding is not necessary. Now, as a non-physician looking at that, and having a couple of different certifications of my own, that doesn’t seem like a very rational thought to me. There are two of your groups that have said they don’t believe they need to be boarded in general surgery. However, it was interesting. We had a cardiothoracic surgeon in the group. We got into the topic or discussion of where cardiothoracic surgery wants to go with their own specialty. It appears that they are beginning to split with different tracts within the field that is straight thoracic, straight cardiac, and perhaps congenital. We were looking at the curricular needs for that individual, and for himself, generally speaking, most of the individuals who want to do a thoracic track also want to do their

Board certification in surgery because they want to do a mixed practice. That is why we came out with the idea. I would agree, based on some of the experiences we’ve had with plastic, that you want to have multiple entry points and exit points for these new trainees. So that kind of idea is more exciting to me, even considering some sort of flexibility in what you do. I hear competence, flexibility, efficiency. Those are kind of the buzzwords that we’re going to work with this. Dr. Organ: My follow-up comment is: Plastic and cardiothoracic are the two most common ones in which, when residents are not successful, they download to general surgery in the certification. Dr. Stoll: That’s correct. I think the other issue that we discussed is that there has to be a fallback mechanism. If, for example, these differentiated curricula are going to work, there has to be a very good understanding that residents who do not make it in the integrated cardiothoracic or integrated plastic surgery program need to have some way they can transfer. Frequently, this means they must back up and do other experiences. Dr. Polk: But the general surgery program that sponsors that cannot become the bailout for all the failures, the residents who go up and lose and say, “Now I want to be one of you.” Dr. Russell: Doris, did your group talk about what is going to be happening in the future about the need for the development of a core curriculum that anybody who wanted to go into any surgical field would have? It leads to one last point. We’re going to have some strange partners in the future, because, for example, the dermatologists want to call themselves surgeons. In fact, they do call themselves surgeons. Our position, as you know, is that if you want to be a surgeon, you’ve got to have the basic core education. You can’t just tack it on at the end of medical residency and then call yourself a surgeon. My question is about the core competency in the program. Dr. Stoll: Our group didn’t talk about it. It is a real concern of mine because you understand that I come at this from a little different view. I’m very carefully looking at what the curriculum ought to look like or what evaluations would be like. If I were to criticize what plastic has done in some of the programs, these new programs, not all of them, there are some of them that are just super, but there are a couple I am not really fond of. The reason is because I don’t believe they have placed enough focus on a core surgery curriculum. There was no agreement on what that core curriculum would be before the integrated programs were developed. So from my perspective, if I were giving advice to any of the groups about how to go about this, that should be where you start. I mean, it is a very laborious, ugly, thankless task to look at what you’re doing now, what you want to keep, what you absolutely agree that you have to have as the core for anybody who calls himself a surgeon. Dr. Bower: One of the issues that plagues me this time of year is making out the schedule for all first-year residents,

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including the designated preliminaries in orthopedics, and the integrated plastics programs. They have, as you have pointed out, set out a curriculum that is ideal for them. I wish that my general surgery residents could follow it. General surgery ends up with the residual rotations because the Associate Dean for graduate medical education says these specialty program directors have it in the Green Book that they have to have these rotations as part of their basic experience. Shouldn’t we in general surgery stake out some territory about what’s core and wonderful for our own general surgery residents? Dr. Stoll: I agree with you. I think that is the way to start, quite frankly, now. Dr. Polk: Everywhere they cherry pick the rotations their people will have, and they couldn’t care less. Dr. Itani: Doctor Stoll, do you think it is still feasible or even acceptable, based on what you’ve presented, to have programs in general surgery that are 6 and 7 years, with years of research in that program? If not, then what is going to happen to the academic departments and research in general? Dr. Stoll: Well, my answer is yes. I don’t think that every program ought to have a research component. They can’t afford it or fund it. They don’t have faculty support or correct kinds of instrumentation or labs or whatever is necessary. Surgery is, to me, the penultimate of the specialties. I’m not saying that because you are surgeons. I lived with surgery for a long time and I appreciate that. I know what it is that you do. That is why I’m here with you and why I wanted to staff the RRC for surgery. I’m one of your supporters, but the issue is you’re going to lose your specialty if you don’t maintain your research base. There are certain institutions that can do it and certain ones that cannot. Those that should not be doing it or can’t do it, shouldn’t do it. Those of you that can, ought to do it and really fight for it. That is my opinion, but not the RRC’s opinion. Dr. Richardson: One of the concerns I have about efficiency is that we have involved very few residents in our discussions about restructuring education. I have talked to several hundred residents about changing surgical training, and many residents view alterations of training in a very different way than we may as educators. If we delete “inefficient” rotations like urology, neurosurgery, plastic surgery, and have only core general surgery, residents ask “when do I ever get to see my spouse?” Some of the less intense rotations are good after being in transplant or cardiac surgery or trauma. They allow us to decompress. Many of the proposed changes are not for educational reasons, but to mollify the discontented. We should beware of the law of unintended consequences. If we try to become too efficient in our training, our 15% resident dropout rate may go to 50%. Dr. Stoll: That’s why we said what we did here. It must be doable. Dr. Richardson: I don’t think many surgeons advocat-

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ing change are talking to the users of the process, which are the residents. Dr. Polk: Doctor Richardson has hit this just so right. There is a huge amount of political decisions being made to mollify the discontented. The unhappy ones are still going to be unhappy after this, and you need to understand this. Some of these are very poor long-term choices. The point Dr. Bower made is what he’s got left is the unhappy, the unattractive, or the particularly demanding slots for his general surgery guys, because everybody else wants to cherry pick all the others. This is a problem. Dr. Beauchamp: I want to talk to the point of maintaining the prestige and the specialty status of general surgery as a specialty. I think all of the efforts to reduce the length of residency is trying to accommodate the people who are going into subspecialties. I completely agree with Hiram. Four years is not adequate to certify! If you want to certify somebody as having basic surgical competence after 4 years that would include a restrictive curriculum, then that might be something reasonable. We could even have it so that somebody could go out into the community and do preliminary trauma resuscitation, appendectomies, cholecystectomies, and a few other less advanced procedures, but we must have a mastery of general surgery and another year or two of advanced surgical training so that people could become master surgeons. This would be the core of general surgery. Dr. Polk: Maybe we’ll come back to that idea, since this is what Britain has done forever. The trouble is you don’t necessarily progress, and a whole lot of them get lost at that level of competence. They don’t pursue further goals. I love that idea of the mastery of general surgery or the master level or some further identification of a person who has really worked to get it all.

Workgroup VI How will RRC monitor and encourage the process? Dr. Polk: Another critical issue is that those of us who are trying to run training programs (program directors, chairs, directors, whatever) are facing a difficult attitude from our accrediting body. Our colleagues are being pushed by the ACGME, their parent body for the RRC for all surgical specialties, to do something about all these issues. We are perceived as the last of the dinosaurs, and they say that somebody needs to kill them and cart away the bones quick. Right now, an issue is how quickly and how rapidly is the RRC going to come up to speed and begin to twist our wrists to accommodate issues about work environment, work hours, and other things. Doctor Richardson agreed to chair what was a very tough subject: how will the Residency Review Committee monitor and encourage the process.

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Dr. Richardson: We actually stayed fairly focused. Most of our time we focused on work issues, although we did have some discussion on competency as well, albeit briefly. I want to recognize the members of our committee. Brad Thomas, a senior student who is going into surgery, Tom Smelzer; a junior student who we hope will go into surgery; Bill Cheadle, our program director; as well as myself. Our group wished to make four points. First, the work hours issue is not going to go away. While one can argue the relative merits of the Libby Zion case; nonetheless it happened and started an inexorable process that continues many years later and will not go quietly away. Secondly, work hours restrictions are important in preventing fatigue, although the data on fatique are somewhat muddled and confusing. Our group, especially the students, felt there was some hypocrisy in the work hours debate, particularly regarding moonlighting, which rarely ever gets on the radar screen but is a huge issue. Many residents who complain loudly about work hours spend more time moonlighting than in their formal training. The inability to moonlight in surgery creates an uneven playing field from a financial perspective for surgical residents compared to many other disciplines. Thirdly, continuity of care must be a priority that’s not abandoned as we change the work hours. Team work is great, but the ultimate responsibility must lie with the surgeon and not with the team. Fourthly, control of work hours is essential to continued recruitment of talented residents into surgery. That is one of the reasons that we are here, and it is important to recognize that these lifestyle issues are real. As a member of the RRC, I know we spend more time discussing work hours than any other issue in our program reviews. Good programs with excellent educational curricula, wonderful residents, and excellent case volumes are cited over the work hours issue. It is something that is of tremendous concern to the RRC.

Our committee had several recommendations on what the RRC should do. First, there are definition issues that the RRC needs to address. What is a work hour? The RRCs have not defined it, and that is part of our problem in trying to accredit programs. Is it in-house call only? What about calls taken from home? Does study time count? How does

moonlighting factor into work hours? Should educational conferences which benefit the individual and are not really service time count as hours worked? So the RRC does need to define a work hour and what’s a reasonable work week. The second thing we felt that the RRC could do is to provide data on work hours using the uniform definitions. In order to do that, though, we have to examine the method of reporting. For example, is this selfreporting? Should residents punch a time clock? Is selfreporting done to an RRC site visitor months or years later, when a resident is unhappy at the chief over something, or is fighting with their spouse or had a bad day. Are all 80-hour weeks the same? Residents generally complain about hard work if there is commensurate training value or educational opportunity. Based on my RRC experience, three types of services get 90% plus of the complaints. Those are trauma, cardiac, and transplant rotation. Interestingly, we get as many letters complaining about the perceived work hour restrictions as we get complaining about working too hard. These letters say, “You are depriving me of my education by your rules.” “I am missing elective cases because I’ve been made to go home. I don’t want to do this. I am alert. I don’t need to be treated like a child with compulsory nap time.” There needs to be a more uniform and fair processes to monitor work hours from the program’s perspective as well as to protect the resident. The RRC deals with the Program Director and/or Chair only. It probably needs work with the entire total faculty. To encourage a culture of compliance on the work hours, we need major faculty “buy in.” In terms of the core competencies, we didn’t say much. We questioned the paper chase aspect versus the meaningful process aspect. How do you protect programs from future liabilities? If we attest a resident competent on a whole variety of things, including issues like interpersonal skills, are we then liable if their interpersonal skills are found wanting at the next level? Should the RRC develop a template for the assessment of core competencies in residency; in other words something to help programs with this issue, or should we let programs go on their own and do it on an individual basis? I always like individualism in programs as opposed to templates, because templates make everything look “cookie cutter,” but perhaps the cookie cutter approach would be a useful one in this situation. Dr. Polk: David, thank you. Let’s hit the second great Jim Maloney paper that nobody ever paid any attention to. Jim has been one of the most creative thinkers in surgery in this country, and he got into something that just epitomized what David is talking about. He tried to correlate what residents thought they learned and how happy they were on different surgical services. At UCLA they had a big, busy service. It had absolutely no correlation he could identify with happiness, unhappiness, performance, education, with the workload. The workload had nothing to do with it. It

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turned out that if the residents felt like they were being taught during the time, that any amount of work was okay; if they weren’t being taught, you couldn’t leave soon enough. It is just a principle we need to reiterate, because what David is talking about is culture compliance. We’re going to tick some people off, but this is a broad-based faculty thing. Teaching is the deal. When you’re not teaching, you ought to find a way to cut your losses and move toward your work hours. That is just recognizing where the strengths and weaknesses are. Dr. Stoll: I think that there are several things that this workgroup brought up that are important. I thought that we could take these back to the RRC and beat up on them a little. First of all, I agree that we really do need some sort of a national survey. Secondly, all these ideas about consistent definitions of those words are excellent. I know that some of this has been done within that ACGME work group, but I am sure there are some areas in here that they have not addressed, and I will take that back to them. The last issue that you mentioned dealt with the template for the competencies. I have that on the pan and ready for you all to look at during the June meeting, so we’ll see how that flies with you. Otherwise, I would say to you that the RRC is clearly on the front line on this, and I believe that they’re really focused on trying to do a good job with this. As with any other group, your cards and letters are gratefully appreciated. We do pay attention to what you say to us, so I would invite those comments from the audience. Dr. Polk: David used this word about a culture of compliance where people think this is important. It’s good to take care of patients, get out of here, get your rest, get your time off. When you’re supposed to be in conference, be there; get an attitude among the faculty that is supportive of all this, and stop the stuff about when men were men! There is a theme in this. We must make that a top thing. Dr. Richardson: The RRC now does certainly recognize the importance of these work hours and lifestyle issues. Unidentified participant: One thing we have not really talked about is that the ACGME are treating all the RCCs as if the residencies are the same. Our people certainly work much harder than other specialties. We regard it, and the residents themselves regard it, basically as an insult that the ACGME would regard surgical residents as the same level of work and talent that it takes to be an endocrinology fellow. I submit that the pay levels, which are equivalent across the line, probably ought to be changed, and we ought to fight to see if those could be changed to get all surgery residents paid per hour. Dr. Polk: That’s a new thing. Dr. Stoll: Can I just respond quickly? I am going to chide surgery for this, because there are very few surgeons that are in leadership positions on the ACGME plenary group itself that makes policy. Now, too, Bryce is coming up next year. He will be the chair, but he’s the only surgeon

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of the 20 odd members of the Board of Directors of ACGME. Now, why is that? Dr. Polk: Well, and part of it, Doris, is a very real thing. For example, George Sheldon is the only surgeon, I think in my lifetime, who’s ever persevered to become the Chair of the AAMC. It means for 15 years you go to a lot of not-very-profitable undertakings and you always are there to vote, you always pay attention, and you do what you’re supposed to. It is saying somebody played the game, and then surgery for a time, to our benefit, had a real representative when it counted. Surgery has a lot of people that don’t do that. Our people make a commitment to the College, but they don’t make a commitment to the American Board of Medical Specialties or AAMC. Dr. Organ: David and Doris have been particularly silent on the work environment and the duty hours for faculty. Do you feel that the RRC has any responsibility in this regard? Dr. Richardson: Clearly, all these issues are important for faculties that are under enormous stress as well. But, there are other issues that faculty members must decide on their own. Dr. Itani: I would like to address the moonlighting issue. It is the job of your institution and your GME committee to come up with a unified policy so that all residents are treated the exact same way as the surgery resident. This is extremely important. Dr. Richardson: Is that done in Houston? Dr. Itani: Absolutely. Dr. Richardson: You’re sure? Dr. Itani: Absolutely. The other issue that is very important is, if you have the resident that is moonlighting, that is going to be within his or her compliance of the 80 hours work week. Dr. Polk: Let’s push on, because we have one whole report to do and a summary. Unidentified participant: One point that Doris didn’t comment on was the idea of getting the message across to the faculty regarding the RRC report. It’s always amazing that the RRC will send 6 or 7 copies to just about everybody, but not to the faculty who actually are the ones who ought to be equally responsible for the effectiveness of the program. So perhaps a suggestion will go back to the RRC that mechanisms need to be involved to put the onus of responsibility not only on the Program Director. Dr. Richardson: On the program and its faculty. I think we really need to do that and find a way to do that. Dr. Russell: I enjoyed your comments. You started off talking about the Zion case, and lots of people work hard. All these investment bankers and lawyers work hard. A lot of people work 24 and 7, but society has weighed in on our profession, and particularly on surgery. I just want to support what you said. We can’t back away, because if we don’t take care of it as a profession, then there is a Congressman from Michigan by the name of Conyers that will be very happy to take care of it for us. The last thing we

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need to have is some rules legislated that we’re going to have to comply with, so I just wanted to support the comment. Dr. Polk: We can’t back away from this. Let me stop for a second, and I want 30 seconds of comments from some of our most sincere guys. Dr. Neubauer: I would like to go back to what we were talking about with the work environment, and just say that there are certain things that we might be able to do here that each individual program could take on. There are two areas where you can help residents. One is what comes down to giving them things that are going to make their life a little easier, options that every other job has, some sort of investment opportunity with sharing by the institution, or some sort of good meal. Any other job you can find something good to eat. Dr. Draus: I would just like to say the finished product cannot suffer. If you’re going to cut and restrict our work hours for the training, we have to have a solid core curriculum, and the finished product should not suffer. Dr. Eric Davis (Louisville, KY): The work week limits are coming. I think it’s a good idea for some internal control as opposed to external control. I’m a firm believer that I want to train over the next 5 years in a way that I’ll be working the rest of my life. I think I’m going to resent some of the restrictions placed on me, but I do think it should be an internal control. Unidentified participant: I think the moonlighting issue is a real one that adds to the disparate experiences. Some of my colleagues make their $40,000 for less than a 40-hour work week and then make $100,000 moonlighting and have a markedly disparate lifestyle. I think that is a real concrete issue. Unidentified participant: One of the issues that came up was as a fourth-year medical student in school seemed to be somewhat inefficient. There is a lot of time that goes wasted, and I just wonder about the option of having an accelerated track as far as integrating a portion of the fourth year with the residency program, rather than streamlining the residency program. Dr. Polk: It’s got a lot to do with money and beans. Dick Knapp, you ought to put that away sometime; the fourth year of medical school represents about a hundred days of constructive education. I know by leaving it where it is, it flows from to deans and medical schools and not to hospitals and departments. It’s a problem. Unidentified participant: I just wanted to say that the issue about moonlighting is real. I have anecdotally heard of surgery programs that did not fill and actually solicited from medical interns to fill in the rotation schedule. I think it is vital to collect that data, because people like the ACGME need to know that simply by restricting our hours, is really not the issue. These people are not tired. They are actually going out there making lots of money. Dr. Polk: I hate to say this after a lifetime of being in a position to know better, but I don’t think until this morning

I realized what a horrible mess the opportunity to moonlight, to make a lot of money, and to work few hours is. It is a horrible discrimination against our residents and all surgical specialties. I never heard it as clear as yesterday about what our problem is in inefficiencies or in destroying the morale of a good hospital. There are some things that have come up here that are, maybe for many of us, first time.

Workgroup VII Sudden development of shortages of surgical specialists Dr. Polk: We gave Dr. Knapp one of the best subjects, which is to talk about potential deficiencies of surgical specialties and what may be the future for needs in our area of work. Dr. Knapp: We reached a conclusion very quickly that we had a competence problem. There were four of us, ranging from a medical student to a chief of service. Since we had no facts, we had a variety of opinions. The way we went about it, after some discussion, was to be impressionist and ask folks to say the first things that comes to their mind when you think about the supply of physicians, either overall or by discipline. So we asked Dr. Nesbitt on the faculty of Urology to say a few words just to get us started. He took us back to the 1950s, when it was perceived that there were too many urologists. There was some downsizing that took place by adding a year, et cetera, then all of a sudden there appeared to be lots of jobs. Now when it comes to urology, at least as I understand it, I’m told that there are at least two or three applicants for every position. Dr. Polk: But remember many of that applicant pool in any specialty is now filled more by overseas graduates than it has anytime in the last decade. They are there, and if that’s a surrogate for something else, use your own judgment. Dr. Knapp: Then we asked Jason Talbott, who has finished his second year in an MD/PhD program, what comes to mind. He said the first thing is the personality-type myths that are fairly common around the institution. In other words, he said: “I was told I am too nice to be a surgeon, which I would like to be.” I think it goes to what you were talking about, Tom. You can hear it. I know the story, and I use it on occasion, about how do you keep a dollar from an orthopod? You put it in a book. How do you keep a dollar from a radiologist? You pin it on the patient. How do you keep a dollar from a plastic surgeon? Can’t do it! I must say while we agreed with what Dr. Russell said about disparaging other specialties, I continued to hear it throughout the morning. It isn’t quite as direct, but it’s there. What do you expect from him, he’s an endocrinologist. Isn’t that what you said? Body language and the way it came across sort of implied something. The other thing that Jason said was his impression when he came here was that this School wants primary care

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graduates. Don’t say you want to be a surgeon if you want to come here. I mean, that’s out of the Dean’s office and the leadership of the School and the impression that is out there. I then asked: Do any of your classmates see an impending oversupply of physicians and do you worry about it? The answer was: No, I don’t, nor do others, either students or residents, which is kind of interesting given what we have been saying. Dr. Polk: That’s a truth that’s been out there for 3 years, and it still hasn’t permeated the student group. Dr. Knapp: We asked Chris Godshall, who is a chief resident in surgery, who made the observation that basically the position availability issue is almost pretty stable. It grew, but it didn’t grow in general surgery. Instead, it grew by emergency medicine and a variety of other fellowships, et cetera. The piece of the thing that is really an accordion is the extent to which medical students made changes in their choices. When I first came in this field, I thought every anesthesiologist was from the Philippines. That is just the way it appeared to me, but that didn’t have anything to do with the positions. It had to do with the choices that young people make. I get the same thing on Capitol Hill about scare tactics. We need to put more money into geriatrics, then I show them the fill rate in geriatrics. The positions are there, but nobody’s choosing those fellowships, for obviously other reasons. Chris also said that his medical alma mater had the same experience where the school wants primary care graduates. So it isn’t just University of Louisville. I think it’s out there, although it seems to be receding, at least to me, elsewhere. We didn’t seem to have agreement on whether or not most students early in their career know what kind of discipline they want to choose. There may be somebody who woke up when he or she was 6 and said he or she wanted to be a neurosurgeon. I’m never sure I met that one, but I don’t know what the general view is on that. My guess would be no, but I don’t know that. We didn’t seem to come to agreement on that. We kind of came to that, in a sense. We’ve sort of ignored market economics. Some studies were done, and people took a look at what they thought was going to be needed based on the so-called managed care closed panel model. That’s what the GMENAC group used, then we had COGME. The point was made that we don’t really know what we’re doing in this arena. To a large degree, one of the reasons we don’t know what we’re doing is the fact that we don’t know what medicine is going to be like. You sort of ask yourself, what is general surgery going to look like 20 years from now? I think that is an important point. About reimbursement, I was a little confused, and I know something about this, but not as much as others. How is it that general surgery has lost ground and some other surgical specialties and other procedure specialties haven’t lost ground? It’s embedded, it seems, in the way in which new technology is put into the things that you do or whether or not you’re doing old things with new technology and not

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getting the credit for it. It seems to me there’s some work needed there that hasn’t. Dr. Polk: I know Tom would take this in the right vein. General surgery has not had an economic-oriented group speaking for it in a selfish fashion as many other specialties have, and we could spend all day on that. You’re absolutely right. It’s absolutely true. General surgery was out to lunch. It is my fault as much as Dr. Organ’s. We were out to lunch at a time while others were paying attention, and we didn’t have the right group, the right organization to push it. Dr. Knapp: Another quick thing is the CPT code and how that all got worked out. Lastly, the gender issue is just right there in front of us. You know, I recall what the family medicine lobby was like in the ’80s and in the state houses around the country. Family medicine is the leading organization out there. I mean, think about it. They forced departments of family medicine in medical schools, many of whom didn’t want them, and they now have them. There are a few private schools, maybe five in the country, who are proudly walking around saying, “I told you so. We never had to do it.” Family medicine did things at the state level. I never hear much from surgery as a state chapter organization. There’s probably some work that could be done there.

We drifted then into the lifestyle issues. One of the ones that I thought was interesting came out of Jason. He pointed out the fact that he was a wrestler in high school. Wrestling never gets on the front page. Nobody really cared very much about what the wrestling team did; it’s kind of how you feel, maybe, as a resident. However, his school did a lot of social things to make those wrestlers feel good, feel important, and feel that they were really different and the best. Sometimes you wonder about this, at the bottom of the pole in the residency environment, if you get beat around day after day, as I have been told happens. There are probably things the Department can do to make people in those positions feel good about themselves. It has to do with food and housing, but there are other social things that can be done, and I think you agreed that that was a rather interesting and useful observation, the last point. Unidentified participant: The other point that he made—Jason, you can speak up for yourself— but the other point that he made was the wrestlers had the toughest workout schedule.

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Dr. Polk: Football scores were on the front page of the sports section, but they were made to feel good in other ways. Dr. Knapp: I think, Hiram, that you made this point: we want a certain type of person. Given the work that you’re going to do, you don’t want to attract people into the discipline, notwithstanding some changes that might be made, who aren’t comfortable in behaving that way. It goes to the point of getting these people out of the specialty who are unhappy in what they’re doing. Are we going to have a shortage of general surgeons? I have this impression it’s out there in spotty areas around the country. I hear the same thing about neurosurgeons. I’ve heard that for a while, particularly in the states of New Mexico and West Virginia. We also need to remember how inaccurate the GMENAC economy reports were and some thought needs to be given to where has general surgery been? What did we used to do? What are we going to do? I thought your observation was interesting yesterday about if we’re going to have these new organs, who’s going to put them in? I guess I never thought about it quite that way, but I thought that was an interesting observation. Dr. Polk: But another thing that’s really important is the workforce issues that we look back upon with just a little bit of hindsight are terrible. The thing that is fueling general surgery today, now I don’t know where it is in 10 years, has been the impact of the baby boomers reaching their 40s where breast, bowel, and biliary surgery are so common historically. The fact that we now have less invasive methods to do that work, that makes it more attractive to everyone. The number of gallbladders taken out in America has doubled, and there is an acceptance on the part of people for minimal access surgery of common diseases that wasn’t on the radar screen when people were trying to do this. If you would have asked me this 10 years ago, I would have seen it as a small blip, like mitral valves. You will catch up with all the kids that had rheumatic fever and it’ll be flat. Dr. Knapp: I ask my colleagues to comment. There’s one last thing we talked some about. Chris made the observation that work doesn’t bother me. I knew what I was doing when I signed up for this. I mean, I get irritated about the point you just made, but I signed up. I knew it when I got into it, so I was reflecting on the fact that we have in our organization a resident part of the organization as well as a student part of the organization. They don’t feel the same way to me as the AMSA [American Medical Student Assocation]. I have yet to meet a surgical resident who wants these hour restrictions. They would like some changes, but they’re not quite there. If, in fact, they don’t really want it, and if it is true that it’s irrelevant to many of the others who do not quite work these hours, what are we doing? I mean, I just can’t quite figure out where it’s coming from except for a few leadership people. Dr. Polk: I had an experience I want to share with you, because it involved my class reunion 2 years ago. One of America’s preeminent psychiatrists is a classmate of ours.

We were stunned when the guy walked up to me and put his arm around me and said, “Hiram, the only guys in our class who are happy are you guys who went into surgery.” I mean, that was an observation 35 years after medical school, that the only guys in our class that are happy are you guys that went into surgical specialties. I could make a litany of why it shouldn’t have been true, but here’s a guy who has no bias and was just sitting here observing a scene with a bunch of old guys who hadn’t seen one another in 30 years, except parenthetically, the guys in our field are happy. The great concern, though, is we are chasing people away before they get the chance to find out how much fun it is. I want to comment on one thing that was in that editorial in AJS 3 years ago [3]. We now have run 44 or 45 students through this lifestyle rotation, with practitioners in group practice of surgical specialties in Louisville or out in the state. Forty out of the 45 students have written the most glowing endorsements of the experience, and the others were mildly happy. This idea of letting students go out and see that the practice of surgery can be fun is real important. You can’t save it until the fourth year when the students have already made a decision about what they are going into. We must push it back earlier and take a week out of an already packed 8 weeks of surgery in a very crazy educational system. This is the kind of accommodation we must make if we’re going to keep people coming in our discipline. Those of us in it are happy and they are doing good, but we can’t escape the fact that we are chasing domestic American graduates away from it, and it is environment and lifestyle.

Workgroup summary Dr. Polk: Let me walk through these ideas quickly. I want to hit the things that I picked out of this morning and the last 2 days. They are not in great order, but I want you to let me know if these are not the ultimate issues. We do need to implement the core competencies and lace them through our curriculum and through our evaluation. The idea of getting involved in institutional quality improvement and changing the label and the content and the orientation of M&M conference is really a good one. This 2-day meeting has tossed another whole set of unfunded mandates on our underfunded Departments of Surgery, who are trying to bootleg all this on the back of shrinking practicing revenue. This idea that all these competencies can be done is just a killer. If you told me I had to have $35,000 to implement this program, I don’t have a clue where I’d find it. The best way is to let a staff member go and then spend it for that. Major issues culled out of all this—Tom, I’m afraid will say this— could you and the Board of Regents at the College develop a scheme for finding a way to use patients for

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our advocates? The comment Susan made toward the end of discussion yesterday was one of the most striking things in this meeting. Could we do what some other self-serving medical groups have done and get patients to speak out for us? I said at the time we do well when we speak for our patients. They might do even better when they speak for us than we do! The concept, which everybody thought was off the wall when Hank Wagner said it yesterday, of trying to find some way to reward people who work longer within the residency and some way that could be tied to paying down their debts, or qualify for benefit programs or retirement benefits, we need to pursue. That’s a different strategy, like the guys who work fewer hours and do more moonlighting, you’re looking at as much as $100,000 differences in income. That adversely and personally affects our residents in surgery. I would have never seen the discussion coming about how much OR inefficiencies suffuse the whole disadvantageous work environment for our residents. I guess I have taken it for granted it goes with the job. It does not have to go with the job. I’ll tell you of an amazing experience we are having with our anesthesia group, which is part of a quality improvement enterprise at University Hospital in which they can now get a patient in the door and intubated within 18 minutes if the patient is on protocol. If the patient isn’t well, it gets done somewhat slower. There’s some efficiency there. I personally think the RRC ought to make a notation in its data gathering about the efficiencies of the integrated hospital ORs for surgical residents. As soon as RRC makes the notation, you can do what you want to with it, but it becomes an issue that you’re being evaluated on, and we will all do better. Beeper abuse we talked about as an issue already. We need to improve personal time. I am going to try to write a conclusion to this, that we in our Department are going to do something about the work hours issue. We’re not going to obfuscate on that. We are going to make a controlled effort to implement better education. We’re going to meet the work hours issue head on. We’re going to identify a number and try to protect that in an environment that talks about balanced teaching as well as getting some additional people to be extenders for residents or faculty. Remember, we can be paid a fair amount for nurse practitioners. In Kentucky,

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we get roughly 80 cents on the dollar for that, and I feel stupid for not having done it sooner. They make some things work that are really, really much better. The protection of the resident that tries to provide an honest evaluation from retribution is a big deal. We must find some seamless way that can be done, and then I believe we’re going to get more constructive criticism of our best people. For I guess 20 years, I’ve always taken the graduating chief residents out to dinner before they left, and they always had something to say. It was always constructive, and it was always courteous, but I always walked out of that having heard something that made our program better. Many of the changes we made over a very long time came out of those dinners. I think that if we get the retribution out of this, our committed residents who are so good and believe in our program more than we do can help us by making further refinements. The idea that floated up repeatedly about housing and accommodations and parking—things that were nicer and nearer the hospital as an option for some residents—we need to revisit. That’s an idea that got dropped 30 years ago. It may not be a bad idea, especially if you could make that housing pleasant, and it can be part of the halo effect of trying to create a better overall environment. The abuse of authority is laced through here in several places, and we will try to keep that on the front burner. Bob Barbier made a comment that comes from his public, general hospital background. For some of our hospitals, the residents are the hospital, and that’s a little different. That’s not what you see at the New York Hospital-Cornell and it’s not what you see at Emory University Clinic in Atlanta. In some cases, we have to think this through very carefully, because our residents play different roles in different hospitals. They are clearly pupil over here, and they are mainstream provider over there. We just need to respect those differences. These programs, as we implement them, are going to be incremental costs to our hospital. I don’t think that we can back up from that. I really do believe that. It’s going to be an incremental cost, and we have to be prepared to help the hospitals do that. On the other hand, if we don’t do it, I think students will continue to avoid surgical careers. Doctor Russell’s presentation hit some things that are especially important. He said for comprehensive continuity we must maintain an advisory role model for students and residents. The key thing in this is: do you realize the variety of options surgical services offer to young people for their training? That’s a wide array, from highlighting officeoriented, procedure-specific stuff over here that’s a 9 a.m. to 5 p.m. kind of deal, to the frontline trauma guy over here whose schedule is never his own. We sell all of those experiences and we provide training for all of those skills. The other thing that we didn’t talk about in this seminar is our necessity to produce a broadly-trained surgeon who can operate and nail hips and can do hysterectomies and C-sections because nobody else does that. Nobody speaks

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for the rural general surgeon with the enormous breadth of what he does. We must be very careful when we start those 4-year schemes that we don’t gut some of our programs, especially in mid-America. If you look from Lexington to Nashville to Indianapolis to Cincinnati and back to Louisville, there’s a huge area out here for which we train the medical students for, and we train all those guys. I’ve been here long enough to see the ones that have made a difference and made health care better. There’s not a better example than one training in western Kentucky, which was one of the worst medical places in the state when I came here. We have now had a sequence of our really best graduates, not just in surgery, but the lead surgeon brought the best people behind him in cardiology and in medicine. It’s now one of the very best places in the state. It has had a generation of people who went there behind the leadership of a couple of general surgeons who were broadly trained and made everything better. Again I mention about the senior surgeons who speak poorly of things today. Doctor Russell put this as: “Share the joys of surgery.” Another thing I didn’t expect to come out of our conference was a discussion about disparaging other specialties. Dick pointed out that we fell right into doing it. We said we’re not going to do that anymore, and by the way, hit them again. That’s a needed culture change on our part, because if we disparage others, you can bet they are going to respond in kind. I thought we pushed protected time off over and over and over again. Dr. Cheadle, I think one thing you and I are going to have to work on, is redefine what’s a real curriculum. We’ve got a decent one, but I bet most Departments of Surgery in America don’t have a real curriculum for residents. The curriculum is that you rotate on this, rotate on that, and then do the ENT; that’s a curriculum, it’s the same curriculum that Halsted derived 80 years ago. We need to look at that carefully. I was also impressed that among our many good medical school chairs here, everybody has the same resident attendance rate at conferences, 35%. It’s also the 35% who least need to be there. If we’re going to have a curriculum and teach specifically, we need to find a way that the culture says everybody is released from their other duties for the conference. That time is just as important as anything else. Faculty that don’t support that are not doing the right thing. Doctor Stoll made the point that if you get into shortening residency programs in surgery and you’re going to do something to go to plastic or thoracic, the craziest thing we can do would be to knock out the senior year. If you’re going to do that, we must build some other accommodation in that, because that’s the year where growth, maturity, professionalism, decision-making, responsibility, and accountability come home to roost. So it’s very important that we retain that.

What happens to the people who start that pathway and then fail? If they don’t have the General Surgery Board, they probably can’t come back and practice general surgery. On the other hand, I can just see us all being inundated: “The guy wasn’t quite good enough for thoracic. He’s left-handed and we can’t have a left-handed heart surgeon, so you take him back in general surgery.” That is going to be a problem. You’re going to be inhumane if you don’t take the dregs and the failures of this program back in. That is a tough scenario that I personally feel will really hurt our discipline. I thought the discussion about what are the minimal core skills to be a surgeon was really very important. I would hate to answer that question. I know some of the pieces, but we probably need to redefine that very carefully. Doctor Richardson made a number of points in his presentation that I thought were strictly good, beginning with his statement that this is not going to go away. This little conference is not going to take a position of saying that we’ll reconvene next year and see if we have some better ideas, trying to walk away from it all. The hypocrisy and unfairness of some of this to surgeons in our present work scheme came home more clearly to me than it has before. The definition of work hours, but we must have a caveat about what is a work hour. Is reading at home a work hour?

Clearly, moonlighting needs to be out, as does time clock issues. What’s the best way to do that? Sending people home to miss cases that they need to complete their list of operative experience is a problem. We shouldn’t find ourselves doing that. A surgeon finishing our training will do somewhere between 4 and 8 Whipple operations during his career. All of those are important. That isn’t 200, and it isn’t 20. They need to have seen and done every one of them. You just hate to think that somebody did the workup, took care of the patient, did all the stuff that went into it, and we get in an environment where they can’t take part in something as important as the operation itself. We need Doris and Tom to try to find some honest data about what work hours really are. Bob Barbier just tossed off a very casual thing stating that some surgeons at University of Louisville Hospital said they work 100 hours a week. Well, I never believe round numbers, and that’s the roundest of round numbers. So we know that’s not true, but

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we need to get a sense of what that is as well as a little stratification. If you do call journal reading work time, then we ought to call it journal reading. I don’t mind it being work time, but you ought to call it what it is. OR time, rounding time, time in the clinic, time on the phone, time asleep but on call. Sometimes you get one call a night and, boom, you’re right back asleep. If you start getting two or three calls, and you get one at 4:30, you say: “Am I going to try to go back to sleep or am I going to shower and go on to do my day job?” There’s a different pattern to that, and we need to categorize that in some way that would be meaningful in comparison to other doctors in training. Some of these things are going to spill over to faculty and the story in England. They have the duties that are deleted fall right back on junior faculty. Is that what we mean to do or not? We raised for the hundredth time, Dr. Knapp, the issue about the wasteful inefficiencies about the way the fourthyear medical school is constructed in our schools. I think, Dan, you all agree that’s right. The experience of a fourthyear medical student is not a meaningful educational experience. It’s maybe 100 days in there that amounts to something, but it’s a real gap and could be used better than it is. Dick brought back to the front the gender issues. I want to keep saying that if we don’t do something about our work environment and the hours, we’re going to chase away the good guys, and we’ve already chased away the good girls. I can interview the ones that persist and come through. They are just unbelievable, superstar, all-American kinds of people. But, we can’t live with just that alone. To have an environment that’s viewed as inimical to women is really a problem. You can’t do that. No one can survive as a surgical residency if you chase half of your potential applicants away. We have had good luck, but let me tell you, every time we have a faculty meeting there are people who are very gender discriminating on our faculty and say such things in public. I had a terrible experience of having to literally terminate a set of bedside rounds as little as a few months ago and send everybody home for some astoundingly negative comments about a woman resident in our program. We can’t condone that. You can’t condone this. It was not sexually suggestive, but the complaint was gender biased. Was that all right? We must take a stand about the women, and I think some of us are wrongly chasing them away. We’re probably ahead of the curve, but you just can’t lose any of them. I thought the little story about making the wrestlers feel good for different reasons is a pearl. I think we need somewhere to find a way to share with our people some fun thing, that we realize what special people they are and what special things they do. I think the story to this that’s good is the people in surgery are happier. I think we’re running a huge risk of chasing away other undecided people that we could desperately need. Dr. Organ: First of all, Hiram, I’d like to thank you and Rod for convening this. This dialogue needs to continue.

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There are a number of complex issues. As I said, the solutions to these problems are professional. They are not political. They are not legal. They are not legislative. I think one of the things I’d recommend for the Program Directors would be to read the Green Book. I know that sounds pretty simplistic, but I’m amazed at the number who don’t read the Green Book. There’s a very clear statement in there about moonlighting, which really puts an onus of responsibility in the hands of the Program Director, not counting the fact that they’re on an unequal playing field with the other medical residents. We are not going to get any meaningful resolution to these complex problems unless we initially, aggressively, prudently deal with the end point of everything that we do, and that is the operating room. We’re going to have to be amenable to change, while we change some of our traditional values, and this is embarrassing. You might want to go back and read the Archives of Surgery on the gender gap in modern surgery [4] and the one on rural surgery [5] about 2 years ago. Hiram, thanks very much for inviting me. Dr. Russell: I think it’s been a great conference. I think what we’re trying to do is gain consensus on a lot of very difficult issues, and I commend you and Rod for organizing this meeting. I also think it’s being played out in other parts of the country. We need to gain consensus on a lot of these issues. We cannot resolve this in Louisville in order to make changes so that we are not talking about the same thing next year. This has to be played out in all our various locations, and I think it is. At our regional surgical meetings, we should spend time on this as well. Thank you. Dr. Stoll: I again thank you. I’d like to say that I think we’ve reached a stage here in what we all do for a living where there’s political, social, financial implications that are tremendous upon the specialty, and they are impacting upon the educational process. We all need to work together to step up to the plate and come to some reasonable solutions to some of these problems. Dr. Polk: Because Doris said it, she means it. It doesn’t mean we study this next year or we do nothing while we study. Dr. Knapp: The main point that I think might have been underemphasized was the point that you brought up as a result of what Bob Barbier said. I think in large institutions in many of the parts of the country, we’re basically using the educational program to take care of the uncompensated care

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program. Just look around the country, from Los Angeles County to Creighton Memorial to Jackson Memorial to New Orleans, et cetera. I think the extent to which the institution has to use residents because there are no faculty or no physicians around or they’re operating just with a few physicians, those institutions are in a much different position than, for example, the Mayo Clinic or anybody who’s in the suburbs. I think the residents have very different roles, and my own guess would be, in the absence of any data, that it’s in many of those kinds of institutions where that responsibility is causing a lot of the stress. There are still a fair number of institutions that have a private service and a staff service, but it’s there. There is a very different role for the resident in that service than there is in the other service. I think it is related to the hours issue, and I don’t know that there’s much to be done about it, because that issue isn’t going to go away. I think it needs to be understood by more people in that fashion. I think this has been a wonderful conference, Hiram. I really appreciate the chance to be here. Thank you. Dr. Taylor: I told you earlier that I thought that this meeting exceeded my expectations. There were a lot of questions. The enthusiasm that the participants brought to this and the issues raised in the discussions actually exceeded my expectations. From a personal standpoint, I just want to thank everybody who participated. I think it will go a long way towards helping. Dr. Polk: I keep saying last word, but Lynn has been a great friend of mine forever. Are there special things in this that impact on our largely African-American medical students at medical centers that we’re missing in this focus? Dr. Weaver: The primary problem is economics, in terms of what does it cost. Dick answered the question in terms of most of the programs. The minority programs are situated in those public hospitals. For example, my program is at Grady, and one of the things I tell my residents when they interview for the programs, is that this is tough. You know, you’re going to work hard if you come here and you’re not going to have that VA rotation where you have some time off or that private hospital rotation. It’s only a few months out of their entire 5 years where you’re going to be able to feel like you’re a real doctor and treated in a way that’s acceptable. My residents spend time taking people to the CT scanner because there’s no transportation. They draw all the bloods because if they wait for the lab people to draw the bloods, it would be 2 weeks. It is a tough

rotation. I would say that we have to find a way to pay for them. It is clear that, at least to me, this meeting has been wonderful. I thank you Hiram and Rod for letting me come. It has given me a lot of ideas as to how to improve our residency without money, but indeed it’s going to take money in the end point, in trying to find it. So I think it’s going to affect Howard also. Howard, just to name names, has just gone through a very serious ACGME review. I know the same problems are going on with King-Drew, in Los Angeles, and knock on wood, we’re okay, but we have a review in another year. We have to be very careful with that. Dr. Taylor: I just want to emphasize that this is where the RRC is going to have to enforce their requirements. They are going to not just want to, but there’s got to be some bite, because this is discriminatory. We can’t have that. We’ve got to make institutions that are using residents this way accountable. Dr. Russell: I’d just like to say one thing about money, because money always gets into the issue. Remember that all this money is going to graduate medical education, which must make us accountable for the way we spend the money. I think that’s an important issue. The other thing, which really comes back to professionalism, is that we spend a lot of money in this country on health care. If you read Cooper’s articles [6], it’s going to be more and more, health care as a percentage annual of gross domestic product. There are a lot of ways to analyze this, so throwing more money at the problem is certainly one way to solve it, but I’m not holding my breath for that to happen. Looking at ourselves—let’s look inwardly. Is there waste in the system? That can be a source of income. Now, that’s a tough nut to crack, because everybody thinks that it’s not a waste when it comes to them. But if they look at some other department, you see waste there; you don’t see waste in your department. So I throw that out as a means of income. Dr. Polk: I just want to say that as part of our visit next week to Rob Mentzer at the University of Kentucky, and then further the Joe Fischer birthday in Cincinnati, we are reporting some amazing experiences with surgeon-led costcontrol efforts. You can save money in your own place. It is a game for everybody, and the savings are small, but they’re incremental. When you start adding up reducing a day on length of stay and reducing $1,000 on toys you didn’t use in an operating room, you’ve made it better. That’s released some money that ought to be for somebody’s benefit as Dr. Russell has said. Dr. Spratt: When you get into the business of core curriculum or defending the need for reimbursement, you’ve got to be a lot better at articulating standards of practice. I love general surgery, but I also recognize that we do a lot of random things that are not well articulated as to their value as a basis for arguing in favor of reimbursement. I think that’s hurting us financially and the remuneration of our residency program. It’s something we need to think a lot about and address more thoroughly.

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Dr. Organ: I had an interesting conversation the evening I came in with Dick Knapp. I was telling him that I knew that our reimbursement per resident was $91,000, and he kept asking me the embarrassing question: “Do you have any idea what that funding is for?” I think he said to me we’ve got to know the issue, because we’re on the front line now. We really have got to understand the issues. One of the things I instituted about 5 years ago was an economic mortality and morbidity conference. I wasn’t only surprised what the residents didn’t know about the costs, but what I didn’t know. So I think these are little things that we can implement without federal legislation and make our specialty stronger and more inviting. Dr. Polk: Amen! Travel safely home and know that we are very much appreciative of your coming.

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References [1] Richardson JD, Polk HC Jr, Barber RL. Ethics and surgery: bedside teaching and learning. Bull Am Coll Surg 1982;67:10 –3. [2] Blondell RD, Looney SW, Krieg CL, Spain DA. A comparison of alcohol-positive and alcohol-negative trauma patients. J Stud Alcohol. 2002;63:380 –3. [3] Polk HC Jr. The declining interest in surgical careers, the primary care mirage, and concerns about contemporary undergraduate surgical education [editorial]. Am J Surg 1999;178:177–9. [4] Dresler CM, Padgett DL, Mackinnon SE, Patterson GA. Experiences of women in cardiothoracic surgery: a gender comparison. Arch Surg 1996;131:1128 –34. [5] Waddle WB. Rural surgery: opportunity or minefield. Arch Surg 2000; 135:121–2. [6] Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Affairs 2002;21:140 –54.