- Email: [email protected]
The American College of Surgeons’ role in surgical education of the future
2001 APDS SPRING MEETING: PART I
The American College of Surgeons’ Role in Surgical Education of the Future Thomas R. Russell, MD American College of Surgeons, Chicago, Illinois INTRODUCTION Government groups and media reports charge that patient injuries and deaths are often attributable to medical and surgical errors, stirring heightened demands for accountability by health care professionals. As a result, surgical education and improved surgical competence are among the bellwether issues facing the American College of Surgeons. In this article, I will share with you some examples of how the College is addressing these matters and highlight some of the ways in which the Association of Program Directors in Surgery, the Association for Surgical Education, and other surgical education groups may work together to best manage these issues. Four specific topics are relevant to this discussion: (1) continuing medical education, (2) competence and maintenance of certification, (3) the need to provide residents and medical students with the skills they will need before entering practice, and (4) advocacy on behalf of funding for graduate medical education (GME).
CONTINUING SURGICAL EDUCATION The American College of Surgeons was founded primarily for the purpose of ensuring that surgeons had opportunities to maintain and advance their knowledge and skills. That mission remains relevant today. Traditional educational opportunities we have offered to Fellows and other interested individuals include the annual Spring Meeting for general surgeons and the annual Clinical Congress for surgeons in all specialties. Additionally, the College presents the Surgical Education and SelfAssessment Program, an at-home study program that allows surgeons to fulfill their requirements for recertification without leaving their practices. Lately, though, Fellows have a strong desire for enhanced opportunities to participate in continuing medical education (CME) opportunities and to verify their educational credentials. These requests have arisen in response to increasing concerns about medical errors and quality of care. The College has
Correspondence: Inquiries to Thomas R. Russell, MD, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611; fax: (312) 202-5016; e-mail: [email protected]
heard the call and, as part of an overall strategic planning process, is unearthing new ways to appropriately and proactively acknowledge the needs of its Fellows. To help us respond to the demand for improved CME opportunities, last year, the College established a new Office of Continuing Medical Education, which has 2 major objectives: 1. Serve as a unified, coherent, and cohesive organization through which the CME mission of the College can be administered and achieved. 2. Undertake a program of joint sponsorship of CME activities in partnership with surgical organizations and societies that the College holds in esteem. Joint sponsorship of CME programs is a new arena for the College but should be a favorable move for all involved. Because the College can accredit CME programs nationally, the possibility of simplifying the accreditation process for surgical organizations through joint sponsorships with the College and for accomplishing this goal at a reasonable cost to those organizations is very feasible. In addition to the Office of Continuing Medical Education, the College is in the process of drawing the blueprints for a new Division of Education. In February, we hosted a strategic planning conference for education, which 23 individuals attended. Participants were drawn from the range of surgical specialties, as well as academia, nursing, and general practice. The group agreed that the College needs to revise its education mission statement and that a search should begin to hire a new Director of Education. The primary responsibilities of the director would be to develop a mechanism to ensure all educational programs meet the College’s standards and principles. The director would focus on the areas of (1) improving current practices, (2) cutting edge education in the competencies, and (3) looking to the future to keep abreast of new techniques. Specific objective of the Director of Education would be to: 1. Redesign the Clinical Congress. 2. Develop an American College of Surgeons approach to new teaching techniques and to partner with specialty societies. 3. Develop self-directed learning instruments for the Web and CD-ROM.
CURRENT SURGERY • © 2001 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/01/$20.00 PII S0149-7955(01)00484-6
583
4. Nurture relationships with industry to achieve future educational goals. 5. Establish relationships with specialty organizations for mutual exchange of ideas to enhance the collective mission of improving patient care through education. 6. Ensure that College representatives attend specialty meetings. On another CME front, the College has launched a “Webcasting” program that allows surgeons who could not physically participate in the 2000 Clinical Congress to have online access to the information provided during the meeting’s individual sessions. This program just became available through the College’s website, www.facs.org. We hope to expand this pilot project in the future to capture more activities at the Clinical Congress for those surgeons unable to attend. Additionally, it is now possible for surgeons to earn CME credit through the Journal of the American College of Surgeons on-line. This is just the beginning. Indeed, the Internet will be increasingly important as we use it to make customized educational programs available to our Fellows in their offices. In another innovative move, the College recently has fostered the development of a National Ultrasound Faculty under the leadership of Steven R. Shackford, MD, of Burlington, Vermont. This group has organized a series of “hands-on” ultrasound courses in a modular structure, which have been presented at national College meetings for the past several years. We are now ready to export the courses to other surgical meetings. Remaining under the sponsorship and management of the College, the first 2 courses will be presented in the spring of this year in Cancun, Mexico, in conjunction with the Southwestern Surgical Congress, and in Atlanta, Georgia, as part of the meeting of the Society for Surgery of the Alimentary Tract. Additionally, we intend to work more closely with the College’s 67 U.S. chapters to bring educational programs to surgeons’ “front doors.” I expect the College to offer educational programs that chapters can incorporate into their meeting agendas, such as hands-on courses pertaining to new technology and workshops on practice management, ethics, and so on. The College plans to generate an array of creative responses to surgeons’ expectations of better, expanded, and more accessible CME programs. We will continue to brainstorm in this area and look forward to receiving your suggestions on how we can improve as this ongoing process evolves.
ROLE IN THE “COMPETENCE MOVEMENT” Additional and more diverse CME opportunities represent just 1 venue that the College is pursuing in its efforts to help surgeons stay abreast of surgical advances and maintain their certification. The College also is playing a cooperative role in the burgeoning competence movement. For example, we are enriching the body of knowledge available about clinical guidelines and “best practices” through our 584
ongoing efforts in clinical trials and evidence-based surgery. The American College of Surgeons Oncology Group allows surgeons to enter patients into clinical trials of treatments for cancer in various organ systems. Through American College of Surgeons Oncology Group, both academic and clinical surgeons can actively participate in resolving the challenges of cancer care. Their investigations will lead to a better understanding of what does and does not work, and their consequent conclusions will determine “best practices.” Further, we are looking at ways to educate surgeons so that they are basing their decisions on scientifically provable theories, not instinct alone. Surgeons must have demonstrable objectives, goals, and outcome measurements. Therefore, we are now beginning to ask questions about how we ensure that more of our CME programs are rooted in problem-based learning. With problem-based learning, surgeons share with each other specific problems that they have encountered in their practices and focus on what could be done to ensure better outcomes. We have added more problem-based educational courses to the Clinical Congress over the years, and we intend to expand this trend. To help the College explore its possible influence in the competence movement, we have redirected 1 of 2 standing committees to center its attention largely on this issue. The American College of Surgeons’ Board of Governors’ Committee on Physician Competency and Liability has developed a multidimensional, long-term approach to help assess and verify Fellows’ competency. At this point, the committee’s efforts center mainly on gathering information and educating surgeons about medical errors: how they can be reduced, and how competence can be improved. Additionally, the committee is encouraging the College’s leadership to explore the possibility of obtaining a grant from the federal Agency for Healthcare Research and Quality (AHRQ). Last November, AHRQ announced that it is funding 6 new research projects designed to improve patient safety by identifying and preventing avoidable system errors. Meanwhile, the Board of Regents’ Patient Safety and Professional Liability Committee is rewriting our longstanding Patient Safety Manual to add more information about standards that surgeons should follow to protect their patients from injury or harm. In addition, the College is working with other groups that are examining the issue of competence, including the American Board of Surgery and the American Board of Medical Specialties (ABMS). Both bodies have established task forces that are examining the competence issue and crafting proposals to help increase surgical competence. We are monitoring their activities and plan to work very closely with them as they cultivate their recommendations. In all, the College intends to play a pertinent role in the ongoing efforts to measure and define surgical competence. Because program directors and surgical educators in general already know a great deal about teaching, evaluating, and measuring surgeons’ capabilities, we hope the Association of Pro-
CURRENT SURGERY • Volume 58/Number 6 • November/December 2001
gram Directors in Surgery, the Association for Surgical Education, and other surgical education organizations will help us to discern how we can help surgeons assess and sharpen their skills and knowledge.
INSTILLING COMPETENCY EARLY ON You are well aware that it is critically important for residents to have infinite opportunities to sharpen their command of surgery by working with new technology in a variety of settings and under the supervision of experts. Indeed, a surgeon’s level of competence is often prescribed during residency training. Those habits, reasoning abilities, and techniques acquired while in training will stick with surgeons throughout their careers. The College is committed to working with surgical educators to ensure that surgical residents achieve a high level of competence before they treat their first patient without an attending’s supervision. To help surgical educators refine their abilities as teachers and administrators of training programs, the College presents an annual Surgeons as Educators Workshop. This 6-day course emphasizes the needs of adult learners and the strategies that contribute to an optimal learning environment for medical students, surgical residents, colleagues, and others in the health professions. Specifically, the workshop addresses teaching skills, curriculum development, educational administration and management, and performance and program evaluation. Additionally, we offer an assortment of educational seminars designed with the young surgeon and surgical resident in mind. To help instill a commitment to lifelong learning and evidencebased medicine, the College presents a biennial Young Surgical Investigators’ Conference to assist surgeon-scientists who are entering the process of obtaining extramural, peer-reviewed grant support for their work. The goal of these conferences, which are held with staff of the National Institutes of Health (NIH) in attendance, is to introduce young surgeons to the process, the content, the style, and the people involved in successful grant writing and interactions with the NIH. Additionally, the College has long offered scholarships and fellowships to promising surgical residents and Fellows engaged in academic pursuits and has presented awards for outstanding research papers in all areas of surgery. Further, the College has a standing Committee on Surgical Education in Medical Schools. The responsibilities of this committee include: 1. Keeping the Fellowship informed of surgery’s place in the medical school curricula and encouraging all Fellows of the College to accept their responsibility for teaching medical students. 2. Cooperating with medical schools to provide medical students with adequate education in general surgery and the subspecialties to ensure that they have sufficient knowledge to practice effectively as a generalists. 3. Considering how to give all medical students the opportunity to know enough about surgery and the surgical special-
ties so that they may intelligently select a field of specialization. 4. Evaluating how to provide appropriate courses so that students who aspire to a career in surgery can prepare themselves intensively for it. 5. Cooperating with medical schools and other committees and organizations that are involved in similar educational issues. 6. Improving means of inculcating the principles of practice and ethics during the medical school years. Another College group that is examining the needs of young surgeons and residents is the Candidate and Associate Society of the American College of Surgeons. This organization unites residents and young surgeons from all surgical specialties in a forum where they can express and analyze their concerns among their peers. More than 6000 residents and Associate Fellows belong to this group, and we are working to make sure the program will appeal to the broadest possible audience of surgeons in training and to those who are relatively new to practice. Perhaps the area of expanded educational opportunities for residents is another in which our chapters can be of assistance. For example, our Washington, DC, chapter currently works with program directors to host semiannual all-city grand rounds, an annual basic science review course, and an advanced operative strategies course for chief residents. The latter program allows residents to practice advanced surgical techniques on cadavers and under the supervision of local surgeons who have mastered the related procedures. Interestingly, and almost diametrically opposed to all that we know about preparing competent surgeons, the residency review committee for dermatology of the ABMS is seeking to establish a subspecialty in dermatological surgery. As a first step toward instituting the new subspecialty, the residency review committee for dermatology has submitted proposed training program requirements to the Accreditation Council for Graduate Medical Education (ACGME). The proposal calls for creating a 12-month fellowship program in dermatological surgery. Fellows who complete this highly abbreviated and surely inadequate program would then be eligible for board approval. The College has significant concerns with the proposed program requirements, and we have expressed our views in a letter to the ACGME. In any event, the College currently has dedicated a number of its programs and activities to advancing surgical training, to supporting surgical educators, and to ensuring that all surgeons entering the profession are proficient in the skills and techniques necessary in practice. To continue this tradition and to make it more relevant in today’s training and practice environments, I anticipate that groups such the Association of Program Directors in Surgery, the Association for Surgical Education, and other surgical education organizations and the College will be working more closely together.
CURRENT SURGERY • Volume 58/Number 6 • November/December 2001
585
FINANCING OF GME Unfortunately, despite all of our best efforts to improve surgical education, government interference and budgetary cuts have made it much more difficult for our academic medical centers to attract “the best and the brightest” to surgery and to educate and train them. Perhaps the most glaring infringements on academic medical centers were included among the provisions in the Balanced Budget Act of 1997. The Balanced Budget Act: 1. Capped the number of residents for direct medical education payments to teaching hospitals at the number included in each teaching hospital’s cost-reporting period ending on or before December 31, 1996. 2. Reduced the indirect medical education adjustment, which compensates teaching hospitals for indirect costs attributable to the involvement of residents in patients care. 3. Offered financial incentives to teaching programs that voluntarily reduce the number of residents they train. Fortunately, last year, the Medicare, Medicaid, and State Child Health Insurance Program Benefits Improvement and Protection Act was enacted. This legislation provided a modicum of relief for GME financing, calling for a 2-year freeze on scheduled reductions in payments to teaching hospitals for indirect medical education costs. Nonetheless, provisions in the Balanced Budget Act and other governmental threats to GME are making it increasingly difficult to attract bright, dedicated young people to medical school and rigorous residency training programs. As it is, medical students face immense educational expenses sometimes followed by a long period of postgraduate training, carrying with it an alarming rise in personal debt. Hence, the entire surgical community needs to be very vocal in expressing their views on GME and sustaining financial support for resi-
586
dents. The College, through its Washington, DC, Office, has traditionally lobbied heavily to ensure the financial integrity of our training programs, collaborating with and assisting the American Association of Medical College. For instance, we have been supportive of proposals that would sustain GME financing by requiring all payors that rely on residents to provide services to their beneficiaries to pay into the GME system. In other words, GME funding would come not from Medicare revenues alone, but from managed care organizations as well. Regardless of what approach to safeguarding GME proves most tenable to policymakers, the College is striving to broaden our outreach and influence in this area, and we anticipate that we will be working with surgical education organizations to define the specific resources needed to support the education enterprise.
CONCLUSION Continuing medical education, the competence movement, expanded educational opportunities during residency training, and funding for GME are increasingly important issues for the College. I am very sanguine about the future role of the College in surgical education, despite whatever barriers the government or third-party payors may put in our way. Further, I see many opportunities for all surgical groups to join together in our crusade to ensure that all surgical patients receive care from the best-trained, most skilled surgeons. Together, we will not only survive these turbulent times, but also will be able to bring about a better future.
ACKNOWLEDGMENT I would like to offer special thanks for the editorial assistance of Ms. Diane Schneidman, Senior Editor of the Bulletin of the American College of Surgeons.
CURRENT SURGERY • Volume 58/Number 6 • November/December 2001
The American College of Surgeons’ Role in Surgical Education of the Future Thomas R. Russell, MD American College of Surgeons, Chicago, Illinois INTRODUCTION Government groups and media reports charge that patient injuries and deaths are often attributable to medical and surgical errors, stirring heightened demands for accountability by health care professionals. As a result, surgical education and improved surgical competence are among the bellwether issues facing the American College of Surgeons. In this article, I will share with you some examples of how the College is addressing these matters and highlight some of the ways in which the Association of Program Directors in Surgery, the Association for Surgical Education, and other surgical education groups may work together to best manage these issues. Four specific topics are relevant to this discussion: (1) continuing medical education, (2) competence and maintenance of certification, (3) the need to provide residents and medical students with the skills they will need before entering practice, and (4) advocacy on behalf of funding for graduate medical education (GME).
CONTINUING SURGICAL EDUCATION The American College of Surgeons was founded primarily for the purpose of ensuring that surgeons had opportunities to maintain and advance their knowledge and skills. That mission remains relevant today. Traditional educational opportunities we have offered to Fellows and other interested individuals include the annual Spring Meeting for general surgeons and the annual Clinical Congress for surgeons in all specialties. Additionally, the College presents the Surgical Education and SelfAssessment Program, an at-home study program that allows surgeons to fulfill their requirements for recertification without leaving their practices. Lately, though, Fellows have a strong desire for enhanced opportunities to participate in continuing medical education (CME) opportunities and to verify their educational credentials. These requests have arisen in response to increasing concerns about medical errors and quality of care. The College has
Correspondence: Inquiries to Thomas R. Russell, MD, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611; fax: (312) 202-5016; e-mail: [email protected]
heard the call and, as part of an overall strategic planning process, is unearthing new ways to appropriately and proactively acknowledge the needs of its Fellows. To help us respond to the demand for improved CME opportunities, last year, the College established a new Office of Continuing Medical Education, which has 2 major objectives: 1. Serve as a unified, coherent, and cohesive organization through which the CME mission of the College can be administered and achieved. 2. Undertake a program of joint sponsorship of CME activities in partnership with surgical organizations and societies that the College holds in esteem. Joint sponsorship of CME programs is a new arena for the College but should be a favorable move for all involved. Because the College can accredit CME programs nationally, the possibility of simplifying the accreditation process for surgical organizations through joint sponsorships with the College and for accomplishing this goal at a reasonable cost to those organizations is very feasible. In addition to the Office of Continuing Medical Education, the College is in the process of drawing the blueprints for a new Division of Education. In February, we hosted a strategic planning conference for education, which 23 individuals attended. Participants were drawn from the range of surgical specialties, as well as academia, nursing, and general practice. The group agreed that the College needs to revise its education mission statement and that a search should begin to hire a new Director of Education. The primary responsibilities of the director would be to develop a mechanism to ensure all educational programs meet the College’s standards and principles. The director would focus on the areas of (1) improving current practices, (2) cutting edge education in the competencies, and (3) looking to the future to keep abreast of new techniques. Specific objective of the Director of Education would be to: 1. Redesign the Clinical Congress. 2. Develop an American College of Surgeons approach to new teaching techniques and to partner with specialty societies. 3. Develop self-directed learning instruments for the Web and CD-ROM.
CURRENT SURGERY • © 2001 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/01/$20.00 PII S0149-7955(01)00484-6
583
4. Nurture relationships with industry to achieve future educational goals. 5. Establish relationships with specialty organizations for mutual exchange of ideas to enhance the collective mission of improving patient care through education. 6. Ensure that College representatives attend specialty meetings. On another CME front, the College has launched a “Webcasting” program that allows surgeons who could not physically participate in the 2000 Clinical Congress to have online access to the information provided during the meeting’s individual sessions. This program just became available through the College’s website, www.facs.org. We hope to expand this pilot project in the future to capture more activities at the Clinical Congress for those surgeons unable to attend. Additionally, it is now possible for surgeons to earn CME credit through the Journal of the American College of Surgeons on-line. This is just the beginning. Indeed, the Internet will be increasingly important as we use it to make customized educational programs available to our Fellows in their offices. In another innovative move, the College recently has fostered the development of a National Ultrasound Faculty under the leadership of Steven R. Shackford, MD, of Burlington, Vermont. This group has organized a series of “hands-on” ultrasound courses in a modular structure, which have been presented at national College meetings for the past several years. We are now ready to export the courses to other surgical meetings. Remaining under the sponsorship and management of the College, the first 2 courses will be presented in the spring of this year in Cancun, Mexico, in conjunction with the Southwestern Surgical Congress, and in Atlanta, Georgia, as part of the meeting of the Society for Surgery of the Alimentary Tract. Additionally, we intend to work more closely with the College’s 67 U.S. chapters to bring educational programs to surgeons’ “front doors.” I expect the College to offer educational programs that chapters can incorporate into their meeting agendas, such as hands-on courses pertaining to new technology and workshops on practice management, ethics, and so on. The College plans to generate an array of creative responses to surgeons’ expectations of better, expanded, and more accessible CME programs. We will continue to brainstorm in this area and look forward to receiving your suggestions on how we can improve as this ongoing process evolves.
ROLE IN THE “COMPETENCE MOVEMENT” Additional and more diverse CME opportunities represent just 1 venue that the College is pursuing in its efforts to help surgeons stay abreast of surgical advances and maintain their certification. The College also is playing a cooperative role in the burgeoning competence movement. For example, we are enriching the body of knowledge available about clinical guidelines and “best practices” through our 584
ongoing efforts in clinical trials and evidence-based surgery. The American College of Surgeons Oncology Group allows surgeons to enter patients into clinical trials of treatments for cancer in various organ systems. Through American College of Surgeons Oncology Group, both academic and clinical surgeons can actively participate in resolving the challenges of cancer care. Their investigations will lead to a better understanding of what does and does not work, and their consequent conclusions will determine “best practices.” Further, we are looking at ways to educate surgeons so that they are basing their decisions on scientifically provable theories, not instinct alone. Surgeons must have demonstrable objectives, goals, and outcome measurements. Therefore, we are now beginning to ask questions about how we ensure that more of our CME programs are rooted in problem-based learning. With problem-based learning, surgeons share with each other specific problems that they have encountered in their practices and focus on what could be done to ensure better outcomes. We have added more problem-based educational courses to the Clinical Congress over the years, and we intend to expand this trend. To help the College explore its possible influence in the competence movement, we have redirected 1 of 2 standing committees to center its attention largely on this issue. The American College of Surgeons’ Board of Governors’ Committee on Physician Competency and Liability has developed a multidimensional, long-term approach to help assess and verify Fellows’ competency. At this point, the committee’s efforts center mainly on gathering information and educating surgeons about medical errors: how they can be reduced, and how competence can be improved. Additionally, the committee is encouraging the College’s leadership to explore the possibility of obtaining a grant from the federal Agency for Healthcare Research and Quality (AHRQ). Last November, AHRQ announced that it is funding 6 new research projects designed to improve patient safety by identifying and preventing avoidable system errors. Meanwhile, the Board of Regents’ Patient Safety and Professional Liability Committee is rewriting our longstanding Patient Safety Manual to add more information about standards that surgeons should follow to protect their patients from injury or harm. In addition, the College is working with other groups that are examining the issue of competence, including the American Board of Surgery and the American Board of Medical Specialties (ABMS). Both bodies have established task forces that are examining the competence issue and crafting proposals to help increase surgical competence. We are monitoring their activities and plan to work very closely with them as they cultivate their recommendations. In all, the College intends to play a pertinent role in the ongoing efforts to measure and define surgical competence. Because program directors and surgical educators in general already know a great deal about teaching, evaluating, and measuring surgeons’ capabilities, we hope the Association of Pro-
CURRENT SURGERY • Volume 58/Number 6 • November/December 2001
gram Directors in Surgery, the Association for Surgical Education, and other surgical education organizations will help us to discern how we can help surgeons assess and sharpen their skills and knowledge.
INSTILLING COMPETENCY EARLY ON You are well aware that it is critically important for residents to have infinite opportunities to sharpen their command of surgery by working with new technology in a variety of settings and under the supervision of experts. Indeed, a surgeon’s level of competence is often prescribed during residency training. Those habits, reasoning abilities, and techniques acquired while in training will stick with surgeons throughout their careers. The College is committed to working with surgical educators to ensure that surgical residents achieve a high level of competence before they treat their first patient without an attending’s supervision. To help surgical educators refine their abilities as teachers and administrators of training programs, the College presents an annual Surgeons as Educators Workshop. This 6-day course emphasizes the needs of adult learners and the strategies that contribute to an optimal learning environment for medical students, surgical residents, colleagues, and others in the health professions. Specifically, the workshop addresses teaching skills, curriculum development, educational administration and management, and performance and program evaluation. Additionally, we offer an assortment of educational seminars designed with the young surgeon and surgical resident in mind. To help instill a commitment to lifelong learning and evidencebased medicine, the College presents a biennial Young Surgical Investigators’ Conference to assist surgeon-scientists who are entering the process of obtaining extramural, peer-reviewed grant support for their work. The goal of these conferences, which are held with staff of the National Institutes of Health (NIH) in attendance, is to introduce young surgeons to the process, the content, the style, and the people involved in successful grant writing and interactions with the NIH. Additionally, the College has long offered scholarships and fellowships to promising surgical residents and Fellows engaged in academic pursuits and has presented awards for outstanding research papers in all areas of surgery. Further, the College has a standing Committee on Surgical Education in Medical Schools. The responsibilities of this committee include: 1. Keeping the Fellowship informed of surgery’s place in the medical school curricula and encouraging all Fellows of the College to accept their responsibility for teaching medical students. 2. Cooperating with medical schools to provide medical students with adequate education in general surgery and the subspecialties to ensure that they have sufficient knowledge to practice effectively as a generalists. 3. Considering how to give all medical students the opportunity to know enough about surgery and the surgical special-
ties so that they may intelligently select a field of specialization. 4. Evaluating how to provide appropriate courses so that students who aspire to a career in surgery can prepare themselves intensively for it. 5. Cooperating with medical schools and other committees and organizations that are involved in similar educational issues. 6. Improving means of inculcating the principles of practice and ethics during the medical school years. Another College group that is examining the needs of young surgeons and residents is the Candidate and Associate Society of the American College of Surgeons. This organization unites residents and young surgeons from all surgical specialties in a forum where they can express and analyze their concerns among their peers. More than 6000 residents and Associate Fellows belong to this group, and we are working to make sure the program will appeal to the broadest possible audience of surgeons in training and to those who are relatively new to practice. Perhaps the area of expanded educational opportunities for residents is another in which our chapters can be of assistance. For example, our Washington, DC, chapter currently works with program directors to host semiannual all-city grand rounds, an annual basic science review course, and an advanced operative strategies course for chief residents. The latter program allows residents to practice advanced surgical techniques on cadavers and under the supervision of local surgeons who have mastered the related procedures. Interestingly, and almost diametrically opposed to all that we know about preparing competent surgeons, the residency review committee for dermatology of the ABMS is seeking to establish a subspecialty in dermatological surgery. As a first step toward instituting the new subspecialty, the residency review committee for dermatology has submitted proposed training program requirements to the Accreditation Council for Graduate Medical Education (ACGME). The proposal calls for creating a 12-month fellowship program in dermatological surgery. Fellows who complete this highly abbreviated and surely inadequate program would then be eligible for board approval. The College has significant concerns with the proposed program requirements, and we have expressed our views in a letter to the ACGME. In any event, the College currently has dedicated a number of its programs and activities to advancing surgical training, to supporting surgical educators, and to ensuring that all surgeons entering the profession are proficient in the skills and techniques necessary in practice. To continue this tradition and to make it more relevant in today’s training and practice environments, I anticipate that groups such the Association of Program Directors in Surgery, the Association for Surgical Education, and other surgical education organizations and the College will be working more closely together.
CURRENT SURGERY • Volume 58/Number 6 • November/December 2001
585
FINANCING OF GME Unfortunately, despite all of our best efforts to improve surgical education, government interference and budgetary cuts have made it much more difficult for our academic medical centers to attract “the best and the brightest” to surgery and to educate and train them. Perhaps the most glaring infringements on academic medical centers were included among the provisions in the Balanced Budget Act of 1997. The Balanced Budget Act: 1. Capped the number of residents for direct medical education payments to teaching hospitals at the number included in each teaching hospital’s cost-reporting period ending on or before December 31, 1996. 2. Reduced the indirect medical education adjustment, which compensates teaching hospitals for indirect costs attributable to the involvement of residents in patients care. 3. Offered financial incentives to teaching programs that voluntarily reduce the number of residents they train. Fortunately, last year, the Medicare, Medicaid, and State Child Health Insurance Program Benefits Improvement and Protection Act was enacted. This legislation provided a modicum of relief for GME financing, calling for a 2-year freeze on scheduled reductions in payments to teaching hospitals for indirect medical education costs. Nonetheless, provisions in the Balanced Budget Act and other governmental threats to GME are making it increasingly difficult to attract bright, dedicated young people to medical school and rigorous residency training programs. As it is, medical students face immense educational expenses sometimes followed by a long period of postgraduate training, carrying with it an alarming rise in personal debt. Hence, the entire surgical community needs to be very vocal in expressing their views on GME and sustaining financial support for resi-
586
dents. The College, through its Washington, DC, Office, has traditionally lobbied heavily to ensure the financial integrity of our training programs, collaborating with and assisting the American Association of Medical College. For instance, we have been supportive of proposals that would sustain GME financing by requiring all payors that rely on residents to provide services to their beneficiaries to pay into the GME system. In other words, GME funding would come not from Medicare revenues alone, but from managed care organizations as well. Regardless of what approach to safeguarding GME proves most tenable to policymakers, the College is striving to broaden our outreach and influence in this area, and we anticipate that we will be working with surgical education organizations to define the specific resources needed to support the education enterprise.
CONCLUSION Continuing medical education, the competence movement, expanded educational opportunities during residency training, and funding for GME are increasingly important issues for the College. I am very sanguine about the future role of the College in surgical education, despite whatever barriers the government or third-party payors may put in our way. Further, I see many opportunities for all surgical groups to join together in our crusade to ensure that all surgical patients receive care from the best-trained, most skilled surgeons. Together, we will not only survive these turbulent times, but also will be able to bring about a better future.
ACKNOWLEDGMENT I would like to offer special thanks for the editorial assistance of Ms. Diane Schneidman, Senior Editor of the Bulletin of the American College of Surgeons.
CURRENT SURGERY • Volume 58/Number 6 • November/December 2001