- Email: [email protected]
Society of University Surgeons statement on surgical resident work hours and education
Volume 132
Number 2
SURGERY AUGUST
2002
Society of University Surgeons Society of University Surgeons statement on surgical resident work hours and education David J. Cole, MD, Monica M. Bertagnolli, MD, and Michael Nussbaum, MD, Charleston, SC, Boston, Mass, and Cincinnati, Ohio
From the Medical University of South Carolina, Charleston, SC, Brigham and Womens Hospital, Boston, Mass, and University of Cincinnati Medical Center, Cincinnati, Ohio
THE SOCIETY OF UNIVERSITY SURGEONS (SUS) represents, as a group, the experienced academic surgeons directly involved in resident teaching. In its organizational constitution the SUS has 3 primary points, 1 of which is “the development of methods of graduate teaching of surgery with particular reference to the resident system.” As such, the SUS has a primary interest in the work and education conditions of surgical residents. The SUS Executive Council, in response to the most recent debate concerning resident work hours and persistent systems failure in resident education, believed that it was important for this organization to define its position on this topic. A subcommittee derived from the Association of American Medical Colleges representatives, committee on surgical education, and committee on social and legislative issues consisting of David J. Cole, MD, (chair), Presented at the 63rd Annual Meeting of the Society of University Surgeons, Honolulu, Hawaii, February 14-16, 2002. Reprint requests: DJ Cole, MD, MUSC Department of Surgery, RM 4206 CSB, 171 Ashley Ave, Charleston, SC 29425. Surgery 2002;132:115-8. © 2002, Mosby, Inc. All rights reserved. 0039-6060/2002/$35.00 + 0 11/6/126012 doi:10.1067/msy.2002.126012
Michael S. Nussbaum, MD, and Monica M. Bertagnolli, MD, was formed. This subcommittee was given the task of creating a position statement on surgical resident work hours that could provide a principled framework from which to approach this problem. The resultant position paper has been approved by the SUS Executive Council and presented for review and comment by the SUS membership at large. BACKGROUND Residency programs in surgical specialties have always been challenging both physically and intellectually. Hard work, long hours, high levels of stress, and a strong emphasis on personal responsibility and accountability have always characterized the training of a surgeon. After the establishment in 1937 of minimum standards for surgical residencies and field surveys of programs, the first of the residency review committees (RRC), the RRC for Surgery, was established in 1950 as a tripartite collaboration of the American College of Surgeons (ACS), the American Medical Association, and the American Board of Surgery (ABS). Similar tripartite RRCs were subsequently established for colon and rectal surgery, neurologic surgery, otolaryngology, plastic surgery, thoracic SURGERY 115
116 Cole, Bertagnolli, and Nussbaum
surgery, and urology. These committees have set high standards of quality for graduate surgical education that are used in evaluation and accreditation of surgical residency programs in the United States. The Accreditation Council for Graduate Medical Education (ACGME), the umbrella organization for all RRCs in medicine, has emphasized that the primary purpose of the residency is to educate physicians and surgeons. By doing so, the ACGME established general guidelines on the scope and content of residency programs and allowed continuous improvement in the educational process. The ACS has strongly supported the ACGME and the premise that graduate surgical education must involve the provision of exemplary and properly supervised clinical care. Further, it is believed that patterns of behavior learned in residency will persist throughout a physician’s professional life. The didactic and practical curricula for surgical programs are driven in part by the requirements of certifying boards and have undergone constant evolution as the practice of surgery has advanced. The environment in which this intense curriculum is carried out must facilitate learning so that the educational experience will be maximized. The working conditions, however, for surgical residents have been changing. The information explosion in medicine, increased bureaucracy, increased ambulatory care, and decreasing hospital staff support, accompanied by an emphasis on inpatient care only for patients who are critically ill have substantially increased both the workload and the stress on surgical residents. Many observers, largely outside of the surgical discipline, have been highly critical of the duty hours that are a current part of the educational environment in surgical residencies. This debate first caught national attention in the mid-1980s after the adverse outcome of a patient admitted to a major teaching hospital. In this case, the issues of responsibility for and supervision of the patient’s care, by both the resident and attending staff, were questioned. Unfortunately, the central issues in this highly publicized “index” case were submerged into a discussion of fatigue and length of resident duty hours, even though analysis of the experiences with the patient concerned indicated that fatigue was not a major factor influencing the tragic outcome. In 1989, an initiative was undertaken in the ACGME to place strict limits on the hours per week that residents would be permitted to work. Many nonsurgical residencies developed systems, such as night float rotations, so that resident shifts could be developed to reduce the hours worked. During the
Surgery August 2002
debate that followed, surgeons became aware that the emphasis on hours worked diverted attention from more pressing problems in residency education, namely the conditions under which residents are asked to work, that is, the working environment and the nature of the educational program. An uneasy truce in this debate was achieved in 1992 after the addition of broad language relative to duty hours and call schedules in the Essentials of Accredited Residencies’1 general requirements and the addition of specific language on hours worked in the special requirements for each specialty. Both the ABS (1992)2 and ACS (1994)3 presented position papers addressing the resident working environment emphasizing the importance of professionalism, continuity of patient care, and the need to improve the work and education conditions for all surgical residents. It was recommended that the RRC for Surgery make the status of the working environment an important consideration in accreditation of programs. The RRC has subsequently taken steps to implement this recommendation with the goal of assuring each patient that the resident assigned will be a “healthy, alert, responsible, and responsive physician.”1 Implementation of these standards, however, is currently problematic. In 1999 the General Surgery RRC cited 36% of programs reviewed for work hours and related requirements violations.4,5 The level of requirement violations remained at 35% for the programs reviewed in 2000.5 Forcing this issue back into the national spotlight, The Committee of Interns and Residents and the American Medical Student Association recently petitioned the Occupational Safety and Health Administration for federal regulation of resident work hours. STATEMENT The following points represent the SUS statement of position concerning the current issues surrounding the residency work hours and education debate: A. The SUS supports the content of the ACS’s Statement on Surgical Residencies and the Educational Environment (1994),3 the ABS position paper on resident working environment (1992),2 the ACS Statement on Fundamental Characteristics of Surgical Residency Programs (1988),6 and current ACGME guidelines for standards on resident duty hours. These documents describe the primary tenants of continuity of care, professionalism, and appropriate supervision as fundamental characteristics of surgical residency programs, and provide appropriate guidelines for
Surgery Volume 132, Number 2
resident duty hours to be enforced by the RRC. We encourage the reading and use of the recommendations put forward in these documents by all program directors, faculty members, and leaders of teaching hospital administrations. B. The SUS strongly disagrees with assertions that specific hours can be arbitrarily defined for surgery residents. It is ill-advised to “carve out” resident duty hours in a way that does not consider the other elements essential to the quality of the educational process. If this occurs, there is significant potential for an unanticipated impact that may be detrimental to high-quality education and safe and effective patient care. Thomas R. Russell, MD, FACS, ACS Executive Director, recently stated that, “the imposition of arbitrary work hours that by law must cease at a certain time does not provide a constructive framework for instilling or developing a value system in young surgeons. Constrained work hours do not prepare residents for the real world of surgical practice and the American College of Surgeons is deeply concerned about the passage of such legislation that would affect work hours, particularly when it sets up barriers to learning.”7 The issue of resident work hours is not the specific matter that must be addressed; rather it is the overall resident educational system and environment. C. The SUS believes that quality patient care and education must be the primary goal of all surgical residency programs. Residents should learn in an environment that encourages learning, teaches ethical principles, and instills a sense of professionalism. The ACS has recently approved the following statement of educational principles put forth by the candidate and associate society of the ACS. This statement is endorsed by the SUS: Surgical residency is first and foremost an educational experience based in direct patient care. Implicit in a residency program is the principle that all patient care provided by residents is safe and well supervised. Patients have a right to expect a healthy, alert, responsible, and responsive physician. It is, therefore, inappropriate for teaching hospitals to rely on residents to perform tasks that are not directly related to either education or patient care; these demands threaten the educational system and are a principal reason for excessive work hours. It is essential that hospitals provide sufficient support personnel to perform these non-educational tasks. It is also essential that residents are provided with appropriate faculty support and supervision, and comfortable facilities in which to rest, eat, study, and have opportunities out of the work environment for personal development. Quality patient care, now and in the future, is
Cole, Bertagnolli, and Nussbaum 117
dependent on graduate surgical education; it is critical to monitor, modify, and optimize the work environment to achieve these important goals. RECOMMENDATIONS The SUS has considered the resident work environment, and has developed the following recommendations and proposals with which to attain the goals presented in our statement: A. Develop Metrics. Adequate metrics need to be conceived and implemented so as to measure the 3 parameters that are at the crux of this issue: (1) the quality of resident learning, (2) the quality of patient care, and (3) the use of resident time in non-educational activities. It is only with these tools in place that one can adequately monitor, modify, and optimize the resident work environment. B. Attain adequate administrative and other hospital support services. Given recent cut backs in hospital payments, there is concern that hospitals may be using residents as cheap substitutes for more expensive labor. The time spent by residents in performing tasks such as transporting patients to the operating room or to radiology is time that could be spent in study or at rest. Budgetary concerns in teaching hospitals have often caused reductions in support personnel, so that residents are expected to perform duties that other nonphysician employees should do. It should be emphasized clearly that this out-of-title use of residents’ time and skills may be a major reason for long training hours at night. Adequate information concerning non-educational activities currently placed on residents needs to be gathered and used to eliminate these unnecessary tasks with a goal of reducing duty hours. C. Avoid arbitrary work hours regulation. Arbitrary limitations on educational hours of training will worsen these stresses, adversely effect the welfare of the surgical patient, and may result in the need to lengthen an already long period of graduate surgical education. Correction of problems in the educational environment and positive programs to address the stresses placed on surgery residents in the burdensome conditions prevalent in today’s teaching hospitals are urgently required to be able to avoid this outcome. D. Support RRC for Surgery oversight. The General Surgery RRC currently has the responsibility for monitoring the working environment. This RRC is considered to be one of the toughest and has cited up to 35% of general surgery programs in the past year. The citations should be reviewed to determine what recurring issues are involved, and
118 Cole, Bertagnolli, and Nussbaum
to verify that none of them are spurious in nature. Subsequently the requirements need to be actively followed. Adverse accreditation actions should occur when repetitive patterns of violations involving the work environment are documented by the ACGME. As a profession, we need to support the General Surgery RRC as the oversight mechanism for surgery programs and work to eliminate workhour violations. As a matter of principle, when we act in a manner inconsistent with our values, the profession is weakened. E. Prioritize mentoring. The role of the academic surgeon needs to transcend that of merely supervision to that of mentorship. This is a role that is undervalued and underdeveloped in some academic surgery programs. The relationship of resident and attending faculty should be mutually supportive. Education of the resident is the primary goal, with exemplary patient care as its cornerstone. Residents should be treated with respect and dignity, and should, in turn, demonstrate personal attributes of honesty, diligence, and responsibility. The impetus for lifelong self-learning must be strong. F. Support debt relief. Initiatives to provide relief for student-incurred debt should be explored and developed. Indebtedness of residents as a result of student loans is a pressing problem. For some, this indebtedness incurred during premedical and medical education forces them during their residency to earn additional money through “moonlighting” activities. The impact of moonlighting on overall levels of fatigue may contribute substantially to a resident’s stress and adversely affect performance. G. Develop new educational models. New educational models need to be explored and developed that would allow for more effective teaching and use of resident time. Application of the educational models should enable surgical programs to establish uniformity in well-defined curricula with an expanded formal education process that allows for the precise assessment of progress. H. Provide adequate funding sources for resident education. Items B and G can only be addressed if there is an adequate level of funding to: (1) provide for the costs of physician facilita-
Surgery August 2002
tors, (2) remedy hospital staffing deficiencies, (3) cover the research costs required to stimulate the development of new educational models, and (4) pay for the implementation of costly surgical residency educational tools. Currently the shrinking clinical revenues and reduced hospital reimbursements do not allow for adequate budgets to realistically address these issues. These deficiencies need to be acknowledged so that they can be addressed at institutional, state, and federal levels. In addition, current Medicare graduate education funding mechanisms that are in place need to be reviewed to ascertain that they are being used in the most effective manner to cover the cost of resident education. CONCLUSION “The surgical profession remains dedicated to the education and training of highly qualified young surgeons. Residency programs must be structured in such a fashion, and with enough flexibility, that the individuals who complete the residency will be the best ... that our system can produce.”8 The SUS believes that those of us who are responsible for overseeing surgical residency programs must strive to meet that goal to meet our obligation to our profession, to our patients, and to the public. REFERENCES 1. Directory of Graduate Medical Education Programs, 19921993. Chicago: American Medical Association; 1992. 2. Position paper on resident working environment. Philadelphia: American Board of Surgery; 1992. 3. Statement on surgical residencies and the educational environment. American College of Surgeons, 1994. 4. Leach D. Resident work hours: the Achilles of the profession? Acad Med 2000;75:1156-7. 5. ACGME Accreditation Data for 1999 and 2000. Accreditation Council for Graduate Medical Education; 2001. 6. Statement on fundamental characteristics of surgical residency programs. American College of Surgeons; 1988. 7. Russell T. From my perspective. Bull Am Coll Surg 2000;85:4-5. 8. Ebert PA. Improving efficiency while maintaining emphasis on continuity of care. In: Proceedings of a conference on surgical resident education. Chicago: American College of Surgeons; 1989. p. 3.
Number 2
SURGERY AUGUST
2002
Society of University Surgeons Society of University Surgeons statement on surgical resident work hours and education David J. Cole, MD, Monica M. Bertagnolli, MD, and Michael Nussbaum, MD, Charleston, SC, Boston, Mass, and Cincinnati, Ohio
From the Medical University of South Carolina, Charleston, SC, Brigham and Womens Hospital, Boston, Mass, and University of Cincinnati Medical Center, Cincinnati, Ohio
THE SOCIETY OF UNIVERSITY SURGEONS (SUS) represents, as a group, the experienced academic surgeons directly involved in resident teaching. In its organizational constitution the SUS has 3 primary points, 1 of which is “the development of methods of graduate teaching of surgery with particular reference to the resident system.” As such, the SUS has a primary interest in the work and education conditions of surgical residents. The SUS Executive Council, in response to the most recent debate concerning resident work hours and persistent systems failure in resident education, believed that it was important for this organization to define its position on this topic. A subcommittee derived from the Association of American Medical Colleges representatives, committee on surgical education, and committee on social and legislative issues consisting of David J. Cole, MD, (chair), Presented at the 63rd Annual Meeting of the Society of University Surgeons, Honolulu, Hawaii, February 14-16, 2002. Reprint requests: DJ Cole, MD, MUSC Department of Surgery, RM 4206 CSB, 171 Ashley Ave, Charleston, SC 29425. Surgery 2002;132:115-8. © 2002, Mosby, Inc. All rights reserved. 0039-6060/2002/$35.00 + 0 11/6/126012 doi:10.1067/msy.2002.126012
Michael S. Nussbaum, MD, and Monica M. Bertagnolli, MD, was formed. This subcommittee was given the task of creating a position statement on surgical resident work hours that could provide a principled framework from which to approach this problem. The resultant position paper has been approved by the SUS Executive Council and presented for review and comment by the SUS membership at large. BACKGROUND Residency programs in surgical specialties have always been challenging both physically and intellectually. Hard work, long hours, high levels of stress, and a strong emphasis on personal responsibility and accountability have always characterized the training of a surgeon. After the establishment in 1937 of minimum standards for surgical residencies and field surveys of programs, the first of the residency review committees (RRC), the RRC for Surgery, was established in 1950 as a tripartite collaboration of the American College of Surgeons (ACS), the American Medical Association, and the American Board of Surgery (ABS). Similar tripartite RRCs were subsequently established for colon and rectal surgery, neurologic surgery, otolaryngology, plastic surgery, thoracic SURGERY 115
116 Cole, Bertagnolli, and Nussbaum
surgery, and urology. These committees have set high standards of quality for graduate surgical education that are used in evaluation and accreditation of surgical residency programs in the United States. The Accreditation Council for Graduate Medical Education (ACGME), the umbrella organization for all RRCs in medicine, has emphasized that the primary purpose of the residency is to educate physicians and surgeons. By doing so, the ACGME established general guidelines on the scope and content of residency programs and allowed continuous improvement in the educational process. The ACS has strongly supported the ACGME and the premise that graduate surgical education must involve the provision of exemplary and properly supervised clinical care. Further, it is believed that patterns of behavior learned in residency will persist throughout a physician’s professional life. The didactic and practical curricula for surgical programs are driven in part by the requirements of certifying boards and have undergone constant evolution as the practice of surgery has advanced. The environment in which this intense curriculum is carried out must facilitate learning so that the educational experience will be maximized. The working conditions, however, for surgical residents have been changing. The information explosion in medicine, increased bureaucracy, increased ambulatory care, and decreasing hospital staff support, accompanied by an emphasis on inpatient care only for patients who are critically ill have substantially increased both the workload and the stress on surgical residents. Many observers, largely outside of the surgical discipline, have been highly critical of the duty hours that are a current part of the educational environment in surgical residencies. This debate first caught national attention in the mid-1980s after the adverse outcome of a patient admitted to a major teaching hospital. In this case, the issues of responsibility for and supervision of the patient’s care, by both the resident and attending staff, were questioned. Unfortunately, the central issues in this highly publicized “index” case were submerged into a discussion of fatigue and length of resident duty hours, even though analysis of the experiences with the patient concerned indicated that fatigue was not a major factor influencing the tragic outcome. In 1989, an initiative was undertaken in the ACGME to place strict limits on the hours per week that residents would be permitted to work. Many nonsurgical residencies developed systems, such as night float rotations, so that resident shifts could be developed to reduce the hours worked. During the
Surgery August 2002
debate that followed, surgeons became aware that the emphasis on hours worked diverted attention from more pressing problems in residency education, namely the conditions under which residents are asked to work, that is, the working environment and the nature of the educational program. An uneasy truce in this debate was achieved in 1992 after the addition of broad language relative to duty hours and call schedules in the Essentials of Accredited Residencies’1 general requirements and the addition of specific language on hours worked in the special requirements for each specialty. Both the ABS (1992)2 and ACS (1994)3 presented position papers addressing the resident working environment emphasizing the importance of professionalism, continuity of patient care, and the need to improve the work and education conditions for all surgical residents. It was recommended that the RRC for Surgery make the status of the working environment an important consideration in accreditation of programs. The RRC has subsequently taken steps to implement this recommendation with the goal of assuring each patient that the resident assigned will be a “healthy, alert, responsible, and responsive physician.”1 Implementation of these standards, however, is currently problematic. In 1999 the General Surgery RRC cited 36% of programs reviewed for work hours and related requirements violations.4,5 The level of requirement violations remained at 35% for the programs reviewed in 2000.5 Forcing this issue back into the national spotlight, The Committee of Interns and Residents and the American Medical Student Association recently petitioned the Occupational Safety and Health Administration for federal regulation of resident work hours. STATEMENT The following points represent the SUS statement of position concerning the current issues surrounding the residency work hours and education debate: A. The SUS supports the content of the ACS’s Statement on Surgical Residencies and the Educational Environment (1994),3 the ABS position paper on resident working environment (1992),2 the ACS Statement on Fundamental Characteristics of Surgical Residency Programs (1988),6 and current ACGME guidelines for standards on resident duty hours. These documents describe the primary tenants of continuity of care, professionalism, and appropriate supervision as fundamental characteristics of surgical residency programs, and provide appropriate guidelines for
Surgery Volume 132, Number 2
resident duty hours to be enforced by the RRC. We encourage the reading and use of the recommendations put forward in these documents by all program directors, faculty members, and leaders of teaching hospital administrations. B. The SUS strongly disagrees with assertions that specific hours can be arbitrarily defined for surgery residents. It is ill-advised to “carve out” resident duty hours in a way that does not consider the other elements essential to the quality of the educational process. If this occurs, there is significant potential for an unanticipated impact that may be detrimental to high-quality education and safe and effective patient care. Thomas R. Russell, MD, FACS, ACS Executive Director, recently stated that, “the imposition of arbitrary work hours that by law must cease at a certain time does not provide a constructive framework for instilling or developing a value system in young surgeons. Constrained work hours do not prepare residents for the real world of surgical practice and the American College of Surgeons is deeply concerned about the passage of such legislation that would affect work hours, particularly when it sets up barriers to learning.”7 The issue of resident work hours is not the specific matter that must be addressed; rather it is the overall resident educational system and environment. C. The SUS believes that quality patient care and education must be the primary goal of all surgical residency programs. Residents should learn in an environment that encourages learning, teaches ethical principles, and instills a sense of professionalism. The ACS has recently approved the following statement of educational principles put forth by the candidate and associate society of the ACS. This statement is endorsed by the SUS: Surgical residency is first and foremost an educational experience based in direct patient care. Implicit in a residency program is the principle that all patient care provided by residents is safe and well supervised. Patients have a right to expect a healthy, alert, responsible, and responsive physician. It is, therefore, inappropriate for teaching hospitals to rely on residents to perform tasks that are not directly related to either education or patient care; these demands threaten the educational system and are a principal reason for excessive work hours. It is essential that hospitals provide sufficient support personnel to perform these non-educational tasks. It is also essential that residents are provided with appropriate faculty support and supervision, and comfortable facilities in which to rest, eat, study, and have opportunities out of the work environment for personal development. Quality patient care, now and in the future, is
Cole, Bertagnolli, and Nussbaum 117
dependent on graduate surgical education; it is critical to monitor, modify, and optimize the work environment to achieve these important goals. RECOMMENDATIONS The SUS has considered the resident work environment, and has developed the following recommendations and proposals with which to attain the goals presented in our statement: A. Develop Metrics. Adequate metrics need to be conceived and implemented so as to measure the 3 parameters that are at the crux of this issue: (1) the quality of resident learning, (2) the quality of patient care, and (3) the use of resident time in non-educational activities. It is only with these tools in place that one can adequately monitor, modify, and optimize the resident work environment. B. Attain adequate administrative and other hospital support services. Given recent cut backs in hospital payments, there is concern that hospitals may be using residents as cheap substitutes for more expensive labor. The time spent by residents in performing tasks such as transporting patients to the operating room or to radiology is time that could be spent in study or at rest. Budgetary concerns in teaching hospitals have often caused reductions in support personnel, so that residents are expected to perform duties that other nonphysician employees should do. It should be emphasized clearly that this out-of-title use of residents’ time and skills may be a major reason for long training hours at night. Adequate information concerning non-educational activities currently placed on residents needs to be gathered and used to eliminate these unnecessary tasks with a goal of reducing duty hours. C. Avoid arbitrary work hours regulation. Arbitrary limitations on educational hours of training will worsen these stresses, adversely effect the welfare of the surgical patient, and may result in the need to lengthen an already long period of graduate surgical education. Correction of problems in the educational environment and positive programs to address the stresses placed on surgery residents in the burdensome conditions prevalent in today’s teaching hospitals are urgently required to be able to avoid this outcome. D. Support RRC for Surgery oversight. The General Surgery RRC currently has the responsibility for monitoring the working environment. This RRC is considered to be one of the toughest and has cited up to 35% of general surgery programs in the past year. The citations should be reviewed to determine what recurring issues are involved, and
118 Cole, Bertagnolli, and Nussbaum
to verify that none of them are spurious in nature. Subsequently the requirements need to be actively followed. Adverse accreditation actions should occur when repetitive patterns of violations involving the work environment are documented by the ACGME. As a profession, we need to support the General Surgery RRC as the oversight mechanism for surgery programs and work to eliminate workhour violations. As a matter of principle, when we act in a manner inconsistent with our values, the profession is weakened. E. Prioritize mentoring. The role of the academic surgeon needs to transcend that of merely supervision to that of mentorship. This is a role that is undervalued and underdeveloped in some academic surgery programs. The relationship of resident and attending faculty should be mutually supportive. Education of the resident is the primary goal, with exemplary patient care as its cornerstone. Residents should be treated with respect and dignity, and should, in turn, demonstrate personal attributes of honesty, diligence, and responsibility. The impetus for lifelong self-learning must be strong. F. Support debt relief. Initiatives to provide relief for student-incurred debt should be explored and developed. Indebtedness of residents as a result of student loans is a pressing problem. For some, this indebtedness incurred during premedical and medical education forces them during their residency to earn additional money through “moonlighting” activities. The impact of moonlighting on overall levels of fatigue may contribute substantially to a resident’s stress and adversely affect performance. G. Develop new educational models. New educational models need to be explored and developed that would allow for more effective teaching and use of resident time. Application of the educational models should enable surgical programs to establish uniformity in well-defined curricula with an expanded formal education process that allows for the precise assessment of progress. H. Provide adequate funding sources for resident education. Items B and G can only be addressed if there is an adequate level of funding to: (1) provide for the costs of physician facilita-
Surgery August 2002
tors, (2) remedy hospital staffing deficiencies, (3) cover the research costs required to stimulate the development of new educational models, and (4) pay for the implementation of costly surgical residency educational tools. Currently the shrinking clinical revenues and reduced hospital reimbursements do not allow for adequate budgets to realistically address these issues. These deficiencies need to be acknowledged so that they can be addressed at institutional, state, and federal levels. In addition, current Medicare graduate education funding mechanisms that are in place need to be reviewed to ascertain that they are being used in the most effective manner to cover the cost of resident education. CONCLUSION “The surgical profession remains dedicated to the education and training of highly qualified young surgeons. Residency programs must be structured in such a fashion, and with enough flexibility, that the individuals who complete the residency will be the best ... that our system can produce.”8 The SUS believes that those of us who are responsible for overseeing surgical residency programs must strive to meet that goal to meet our obligation to our profession, to our patients, and to the public. REFERENCES 1. Directory of Graduate Medical Education Programs, 19921993. Chicago: American Medical Association; 1992. 2. Position paper on resident working environment. Philadelphia: American Board of Surgery; 1992. 3. Statement on surgical residencies and the educational environment. American College of Surgeons, 1994. 4. Leach D. Resident work hours: the Achilles of the profession? Acad Med 2000;75:1156-7. 5. ACGME Accreditation Data for 1999 and 2000. Accreditation Council for Graduate Medical Education; 2001. 6. Statement on fundamental characteristics of surgical residency programs. American College of Surgeons; 1988. 7. Russell T. From my perspective. Bull Am Coll Surg 2000;85:4-5. 8. Ebert PA. Improving efficiency while maintaining emphasis on continuity of care. In: Proceedings of a conference on surgical resident education. Chicago: American College of Surgeons; 1989. p. 3.