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Alternating periods of full time clinical and full time teaching-research responsibility versus all things to all people at all times
JOURNAL
OF
SURGICAL
16,
RESEARCH
124-130
(1974)
Alternating Periods of Full Time Clinical and Full Time TeachingResearch Responsibility Versus All Things to All People at All Times G.F.O.
TYERS,
W. J.
S. A.
M.D.,
PIERCE,
F.R.C.S.(C), M.D.,
F.A.C.S.,
WALDHAUSEN,
M.D.,
IF HE IS TO ADVANCE, the young academic surgeon must salvage enough time for a significant research effort from the demands of teaching, administration, and clinical surgery, including availability for emergencies. The wide range of responsibilities which compete for the academic surgeons time have been well documented [5, 61 and are outlined in Table 1. To some degree the quality of our performance in this maze of commitments (Fig. 1) is mirrored by the dwindling influence of surgery in the curriculum of many medical schools IS]. This trend has been attributed, in part, to the dominance of too many nonclinical curriculum planners, but why was academic surgery not well represented in these crucial councils? One suspects that surgeons were appointed to curriculum committees, but that clinical realities often precluded their regular attendance. With notable exceptions [2] the quality and quantity of surgical teaching have also been questioned. Nine A.M. medical rounds with alert faculty and students and regular coffee and doughnut breaks have been compared with devastating effectiveness to the shifting dullness of late afternoon surgical disposition rounds attended by tired and hypoglycemic surgeons and students [S]. While From the Department of Surgery, College of Medicine, The Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, Pennsylvania 17033. Submitted for publication November 5, 1973.
@ 1974 by Academic Press, Inc. of reproduction in any form reserved.
AND F.A.C.S.
lack of economic motivation undoubtedly plays a role in the steady drop in the number of surgeons engaged in academic practice and in the decline of the strict full time system [4, 5, 71, it is probable that the administratively less complicated world of private practice gains in appeal proportional to a young surgeons frustration at his inability to make a significant impression upon the students, the machinery of the hospital and university, and the many problems requiring medical research. Having defined and accepted the difficulty of successfully achieving balance in the juggling act of academic practice, is there a way to insure an evenness of commitment? One possible solution has been for the young surgeon to spend l-2 years in full time basic research [6]. This does provide valuable experience, but it does not maintain surgical skills or teach management of the many competing facets of academic life, and it may result in permanent loss of a clinician to basic medical science. This need not, of course, be viewed as a disaster for the individual but it is a supreme waste of training. The strict full time system, an alternate solution, has been shown to increase time spent in research [7], but often at the loss of interest and quality in patient care [l, 71. We have attempted a somewhat different approach. During the first 18 months of our association in cardiothoracic surgery, we attempted parallel private practice within a
124 Copyright All rights
F.A.C.S.,
TYERS,
PIERCE,
AND
TEACHING-RESEARCH
WALDHAUSEN:
full time academic institution. Only the clinical service prospered, in spite of a rather ideal physical set-up (Figs. 2A & B) in which physicians offices and research laboratories are separated only by the width of a hall and are within a 5-min walk of all patient care areas including the operating room and emergency room. Clinical emergencies led to poor attendance and preparation for many teaching and administrative functions and cancellation of many research activities often aft’er costly preparation. Students and research associates were frequently discouraged, laboratories under-utilized, and teaching and research productivity low. Many of our research projects involve new equipment in the artificial heart and pacemaker fields and require the active participation of engineering associates who have to travel to the medical center from the main university campus approximately 100 miles away. While understanding the clinicians position with regard to emergencies, there was a marked cooling of these collaborative
Table
of the Academic
1. Responsibilities
PRIVATE
ADMINISTRATIW
problem
with
achieving
and
efforts after one or two no-shows by the surgeon. Just over 1 year ago the two junior members of the division formed a group practice with alternating weeks of full time clinical and full time formal teaching-research responsibility. The participants were well matched in training, age, and spectrum of practice and were, and continue to be, willing to accept each others therapeutic decisions and provide appropriate follow-up.
,
1. The
Surgeon
Clinical surgery Resident and student teaching Research Continuing self-education Medical school administration Departmental and divisional administration Hospit.al administration Governmental agencies (national, state, county) 9. Peer review 10. Medical societies 11. Editorial boards 12. Nonprofessional 1. 2. 3. 4. !5. 6. 7. 8.
I--
FQ.
125
RESPONSIBILITY
balance
in ncndcmic
PRACTICE
surgery.
126
JOURNAL
OF
SURGICAL
RESEARCH,
16,
VOL.
2,
NO.
FEBRUARY
1974 ,’)..,,.....k _.’ ,,,’ ,’ ,’,,’
/
/
1 Library
1
\
‘-\
Lecture .-
Fig. 2. (A and B) Structural organization of the division of cardiothoracic surgery. In general, the patients are on the fourth and sixth floor of the hospital, while the operating room and intensive care unit are on the second floor. The surgeons offices are on the fourth floor in the front, and laboratories are across the hall in the rear of the center portion of the crescent.
Ninety-five percent of our practice would be the staff surgeon is responsible for atdescribed as private, and our institution tendance at the outpatient department contains only private patient rooms with where all patients are seen, attendance at certain exceptions. During his clinical week surgical procedures, availability for emer-
TYERR,
PIERCE,
.4X1>
WALDHAUSEN:
TEACHING-RESEARCH
137
RESPONSIBILITY
THE MILTON S. HERSHEY MEDICAL CENTER THE PENNSYLVANIA STATE UNIVERSITY
Department llJBBIEY,
of Surgery
PENNSYLVANIA
17033
717 534-8328
Septembeh
II,
1973
Mt. John Doe EL7A.t Main S.tJleeA AnqheJte, United .!Ctatti vm
Mt. Doe:
V&g yowr adminnion .to the ca&iothoticic AuhgicU.t AehvhX at The Uieton S. unda the cahe 06 vh. ffeuhey Me&c& Centeh you wehe, on a&~nnaX.i.ngW&A, W&aa S. P&~ce Oh VJL.G. Fhanb 0. Tgm, tihough o&y one 06 these Auhge0n.A opetLcLtedupon you. A dL4advanZageob &iA AyAtm mug be Xhe &AA 06 a c.LoA~ dootah-patient tle..&Cotikip behueenthe ptient and a bingte phybioian. On the 0the.h hand an advantage .i~ dhat wkiee one 06 the docfou may be rxt.&.nding a medicaL mee.&g oh ,&5 unavaieabte 6Oh AOme othen. heabon thme i.b, with hate exception, a bWLgeonau&bee who .ih ,@niC#~ wtih each ptiwu2 i.&WAA, ope4ation, and hodpm COWU~. Thencetie manyotheh bace& blLt we waLLed be tn0A.t
Pleahe
tieheAti?d
.h
g0U.X
heidiOK
ab
a pti&
x0
J%A
AyA.tem.
check one 05 the ,jo&?ow&g: 1 ) no comme&, ( ) fikibedAgAte& (
) dinliked
(
) de& abandoned.
bybtem,
Oh
CUMMEMS:
We w.&? hoed youh hep.tg conbidehed in OWL e66oh& youh coopefui.Cm.
-in Xhe Aticte,4nt to
imphove
con&Ldence. It hea&h
cahe
wi5.Z
detiveny.
be btiwtg Thank you
6oh
SLnceheLy goti, WUm S. Pitice, M.D., F.A.C.S. G. Fhank 0. Tym, M.V., F.R.C.S.(C) Vepahxhent 06 Suhgehy USP/GFOT/ck Fig.
S. Questionnaire
sent to patients
gencies, and patient rounds including applied resident and student teaching. The staff surgeon on research is responsible only
having
open
heart
surgical
procedures,
to his laboratory associates and formal teaching commitments. A weekly period was chosen as this brings both physicians
128
JOURNAL
OF
SURGICAL
RESEARCH,
VOL.
16,
NO.
2,
FEBRUARY
1974
THE MILTON S. HERSHEY MEDICAL CENTER THE PENNSYLVANIA STATE UNIV!ZRSITY
Department of Sqery HERSHEY,
PF.NNSYL.VANIA
17033
717 5344328
PATIENTS
AUhilTTEU
TO THE SERVICE
OF
DR. G. FRANK 0. TYERS AN-V DR. WLLZAM
S.
PIERCE.
bhate hQ.bpOtiib~y i$oh yoWr athe&wnt. &tinaZkg ptiodn to ptient cute and O&y one 06 titie buhgeonb education-hti&eahch obkgatioti . ~hdinahiey w.iU be involved & yowc bwLgiccLe phoceduhe but both may be .invo.k.d ln t&b way, both bWLgeOVIb in youh pJ&? and pobtopUa.tive management. gain 6-g tih you& L&te& and Rhea&en.& b0 ab to bettti abb&t you kt the &&he. D/r.
Each
Phhce
06
and
yaw
Phybitin’b potint
tigh &OS&y b&I&&b
oh.
Tyw
buhgeoti
htiponnibUti ~espotiib.Xity
medic&
q&y h&.&d aMd
and
wiee devotti
ake tkrree-6o1d. The dtif and mabt im~2 Xo provide you, the paaX&, wLth advanced, and bWLgk.& cake. The becond &tipotiibWy &
involvti
the
education
and
by3etlv&ion 06 medical
ti itiuke qtiy rnti cahe doh you and yoti The thLtd henpotiibtiy .ib to conduct &mily now and in the &We. hcAeahe.h ~3 h&p devtiop nw and &phoved methods 06 a?w.aXm&. O&y thhough a Tim appoach can youh phybician’b hope to prrovide you Luith good cahe wkiee cotintig io p~ue nw mtxLica.l hnou.&e.dge a%wugh hCbeahch and attendance at me.&& metingb. hebnident6
16 you have any quentioionn, 06 youh phybiciati. Thank
pLe.abc bhing
thm
~3 the attention
06 one
you.
Fig. 4. Explanation
of practice organization
for cardiothoracic
surgery patients.
into contact with the majority of patients ten explanation shown in Fig. 4 which is admitted to the hospital. given to all patients at the time of admisPatient acceptance has been good. Over sion. Eighty-five percent of the responding patients liked the system enough to supply 50$!6 response was received to an inquiry directed to 80 consecutive patients who had amplification of their support. A perfect open heart surgery following the introducscore is, of course, not possible in the praction of the alternating full time system. tice of medicine, and this type of informaThe questionnaire, sent out approximately tion is not widely available for other prac1 month ago, is shown in Fig. 3. Only 2 tice patterns. patients (2.5%) felt abandoned in this sysResident time has been conserved by tem, and each of these patients had a se- having all patients on any given day the verely complicated administrative or medi- responsibility of only two staff members, cal course which was not the result of the the alternating man or the division chief. alternating practice system. Five percent of Teaching assignments are rarely missed patients did not like the system or did not and emergencies do not interfere with feel that it was adequately explained in ad- preparation. Research productivity has increased significantly with presentations at vance, and we have since prepared the writ-
T1-EHS,
PIEHCE,
AND
W~4LDHAUSES:
national and international meetings now averaging over 5 and publications over 10 per man per year. Research within the cardiothorncic surgical division has been funded by four federal and four state or private grants for total nonuniversity support during the last year of $372,000.00. Over the same period, cardiopulmonary bypass cases increased from 2-3 per week to 5-6 per week, with corresponding increases in closed cardiac and thoracic surgery. The advantages of the alternating week system are outlined in Table 2. A total of 432 thoracic and vascular operations were performed by the two alternating surgeons during the last year. In Table 3 are listed the potential disadvantages of the system. In reference to points 1 and 2, a most sensitive indicator of the depth of a physicians involvement is his willingness to comfort the patients family at the time of a death and to obtain permission for postmortem examinat,ion [ 71. Permission for autopsy examination was obtained in over 75% of patients who died last year, and in well over 75% of cases permission was personally obtained by the staff physician. In reference to point 3, the necessity for referring physicians within the medical center to deal with the senior resident arises from their uncertainty as to which of the staff physicians is on call without consulting the call list. While this may pose a slight inconvenience to t’he referring physician during a period of adjustment, it is more than off-
Table
I. 2.
3. 4.
5.
2. Advantages Periods
of the Alternating Mrthod of Practici
Full-Time
Guaranteed uninterrupted average research t,ime of 30 hr/week h’linimal, if any, loss of clinical income to the department Loss of the disruptive effect of emergency surgery on teaching and research activities Increased role of the resident staff in initial decision making and contact with referring physicians Staff physician familiar with the patient’s problem and previous treatment almost always available
TEACHING-HESEAKCH
Table
129
RESl’ONSIBILITY
S. Disadvantages of the Alternating Periods Method of Practice
Full-Time
1. Some loss of the traditional relat,ionship between an individual doctor and patient 2. Possible decrease in intensit,y of a physicians personal involvement 3. Annoyance to some referring physicians 4. Loss of clinical prestige
set by the increased training provided the resident by seeing the majority of patients prior to staff consultation and decision. Outside physicians generally call the cardiothoracic office and refer their patients without specifying a particular surgeon. With reference to point 4, loss of clinical prestige, one of the participants wive’s reacted to an initial description of the system with, “Well, it’s alright if you don’t want to be a real doctor.” An alternating week surgeon may be compared to a paratrooper who only jumps every other week, and a slightly condescending attitude may be noted on the part of the “real” doctors. However, we believe that by improving the participation of the young academician in teaching and administrative functions and thus his understanding of the workings of his university early in his career and by insuring regular periods of uninterrupted research time, the attractiveness of academic surgery may be increased and the present net yearly loss of academic surgeons slowed or reversed. The system of alternating full time responsibility allows achievement of peak efficiency with a minimum of duplication of effort and is of benefit to house staff, students, and patients, who can count on the uninterrupted attention of one staff member. The potential of this system is especially great for specialty practice in new centers where a small house and teaching staff is faced with a rapidly expanding case load. On the other hand, we feel it would be a mistake to coerce this system upon those to whom it is distasteful. Also, the system, as we use it, may be better suited to a high intensity, relatively low patient
130
.lOURiTAL
OF
SURGICAL
RESEARCH,
volume specialty such as cardiothoracic or neurosurgery and may ofrer no advantage in high volume practices such as otolaryngology and urology. Undoubtedly, other methods of providing protected time for teaching and/or research [2] will also find application. To quote Maloney [7], “The over emphasis on research, the denigration of clinical activities, and the introduction of an elective curriculum have already had measurable effect on the quality of medical education in one school.” Our system is not an attempt to continue this defamation of clinical expertise, but rather to provide each of the facets of the academic surgeons continuum of responsibility, from clinical surgery through research, with proper emphasis and undivided attention during a period of time specifically allotted only to it. An idea without time for demonstration of its value and for persuasion of others to its application is of little value [3.]. Hopefully through protected periods of full time research, surgeons who are actively involved in the practice of medicine may effect earlier transfer of laboratory developments to clinical reality. SUMMARY House staff and medical student teaching, laboratory research, clinical surgery, and university and hospital administrative duties all compete for the academic surgeons time. Teaching, research, and clinical surgery could singularly demand full time,
VOL.
16,
NO.
2,
FEBRUARY
i974
but each supplements the other two in the academic setting. Balance and meaning are lost if one prospers to the detriment of the others,
and
yet,
because
of the
persistent
and non-negotiable demands of clinical practice, teaching, research, and administrative
duties
of necessity
come in a distant
second when competing with patient care responsibilities. The system of alternating full
time
responsibility
allows
achievement
of peak efficiency in both the clinical and research spheres with a minimum of duplication of effort and is of benefit to house staff, students, and patients who can count on the uninterrupted attention of a staff member. REFERENCES 1.
Bunker, J. P. Surgical manpower. A comparison of operations and surgeons in the United States and in England and Wales. New Eng. J. Med. 282:135-144,
1970.
2. Curreri, P. W., and Baxter, C. R. An elective clinical teaching program for first year medical students. J. Surg. Res. 14:114-120, 1973. 3. Dock, W. How the investigative Scot foiled the continental conqueror. Pharos 20:56-58, 1967.
4. Durant,
T. M. Motivation and medicine. 101-106, 1968. 5. Fonkalsrud, E. W. Winds of change in academic surgery. J. &rg. Res. 14:81-86, 1973. 6. Gurd, F. N. The education of the academic surgeon. Ann. R. Coil. Phys. Surg. Can. Pharos
1:284-289,
31:
1968.
7. Ma!oney, J. V. A report on the role of eronomic motivation in the performance of medical school faculty. Surgery 68: 1-19, 1970. 8. Zo!linger, R. M. 9 loser today, a winner tomorrow. Burr. Amel. Coil. isurg. 57:10-16, 1972.
OF
SURGICAL
16,
RESEARCH
124-130
(1974)
Alternating Periods of Full Time Clinical and Full Time TeachingResearch Responsibility Versus All Things to All People at All Times G.F.O.
TYERS,
W. J.
S. A.
M.D.,
PIERCE,
F.R.C.S.(C), M.D.,
F.A.C.S.,
WALDHAUSEN,
M.D.,
IF HE IS TO ADVANCE, the young academic surgeon must salvage enough time for a significant research effort from the demands of teaching, administration, and clinical surgery, including availability for emergencies. The wide range of responsibilities which compete for the academic surgeons time have been well documented [5, 61 and are outlined in Table 1. To some degree the quality of our performance in this maze of commitments (Fig. 1) is mirrored by the dwindling influence of surgery in the curriculum of many medical schools IS]. This trend has been attributed, in part, to the dominance of too many nonclinical curriculum planners, but why was academic surgery not well represented in these crucial councils? One suspects that surgeons were appointed to curriculum committees, but that clinical realities often precluded their regular attendance. With notable exceptions [2] the quality and quantity of surgical teaching have also been questioned. Nine A.M. medical rounds with alert faculty and students and regular coffee and doughnut breaks have been compared with devastating effectiveness to the shifting dullness of late afternoon surgical disposition rounds attended by tired and hypoglycemic surgeons and students [S]. While From the Department of Surgery, College of Medicine, The Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, Pennsylvania 17033. Submitted for publication November 5, 1973.
@ 1974 by Academic Press, Inc. of reproduction in any form reserved.
AND F.A.C.S.
lack of economic motivation undoubtedly plays a role in the steady drop in the number of surgeons engaged in academic practice and in the decline of the strict full time system [4, 5, 71, it is probable that the administratively less complicated world of private practice gains in appeal proportional to a young surgeons frustration at his inability to make a significant impression upon the students, the machinery of the hospital and university, and the many problems requiring medical research. Having defined and accepted the difficulty of successfully achieving balance in the juggling act of academic practice, is there a way to insure an evenness of commitment? One possible solution has been for the young surgeon to spend l-2 years in full time basic research [6]. This does provide valuable experience, but it does not maintain surgical skills or teach management of the many competing facets of academic life, and it may result in permanent loss of a clinician to basic medical science. This need not, of course, be viewed as a disaster for the individual but it is a supreme waste of training. The strict full time system, an alternate solution, has been shown to increase time spent in research [7], but often at the loss of interest and quality in patient care [l, 71. We have attempted a somewhat different approach. During the first 18 months of our association in cardiothoracic surgery, we attempted parallel private practice within a
124 Copyright All rights
F.A.C.S.,
TYERS,
PIERCE,
AND
TEACHING-RESEARCH
WALDHAUSEN:
full time academic institution. Only the clinical service prospered, in spite of a rather ideal physical set-up (Figs. 2A & B) in which physicians offices and research laboratories are separated only by the width of a hall and are within a 5-min walk of all patient care areas including the operating room and emergency room. Clinical emergencies led to poor attendance and preparation for many teaching and administrative functions and cancellation of many research activities often aft’er costly preparation. Students and research associates were frequently discouraged, laboratories under-utilized, and teaching and research productivity low. Many of our research projects involve new equipment in the artificial heart and pacemaker fields and require the active participation of engineering associates who have to travel to the medical center from the main university campus approximately 100 miles away. While understanding the clinicians position with regard to emergencies, there was a marked cooling of these collaborative
Table
of the Academic
1. Responsibilities
PRIVATE
ADMINISTRATIW
problem
with
achieving
and
efforts after one or two no-shows by the surgeon. Just over 1 year ago the two junior members of the division formed a group practice with alternating weeks of full time clinical and full time formal teaching-research responsibility. The participants were well matched in training, age, and spectrum of practice and were, and continue to be, willing to accept each others therapeutic decisions and provide appropriate follow-up.
,
1. The
Surgeon
Clinical surgery Resident and student teaching Research Continuing self-education Medical school administration Departmental and divisional administration Hospit.al administration Governmental agencies (national, state, county) 9. Peer review 10. Medical societies 11. Editorial boards 12. Nonprofessional 1. 2. 3. 4. !5. 6. 7. 8.
I--
FQ.
125
RESPONSIBILITY
balance
in ncndcmic
PRACTICE
surgery.
126
JOURNAL
OF
SURGICAL
RESEARCH,
16,
VOL.
2,
NO.
FEBRUARY
1974 ,’)..,,.....k _.’ ,,,’ ,’ ,’,,’
/
/
1 Library
1
\
‘-\
Lecture .-
Fig. 2. (A and B) Structural organization of the division of cardiothoracic surgery. In general, the patients are on the fourth and sixth floor of the hospital, while the operating room and intensive care unit are on the second floor. The surgeons offices are on the fourth floor in the front, and laboratories are across the hall in the rear of the center portion of the crescent.
Ninety-five percent of our practice would be the staff surgeon is responsible for atdescribed as private, and our institution tendance at the outpatient department contains only private patient rooms with where all patients are seen, attendance at certain exceptions. During his clinical week surgical procedures, availability for emer-
TYERR,
PIERCE,
.4X1>
WALDHAUSEN:
TEACHING-RESEARCH
137
RESPONSIBILITY
THE MILTON S. HERSHEY MEDICAL CENTER THE PENNSYLVANIA STATE UNIVERSITY
Department llJBBIEY,
of Surgery
PENNSYLVANIA
17033
717 534-8328
Septembeh
II,
1973
Mt. John Doe EL7A.t Main S.tJleeA AnqheJte, United .!Ctatti vm
Mt. Doe:
V&g yowr adminnion .to the ca&iothoticic AuhgicU.t AehvhX at The Uieton S. unda the cahe 06 vh. ffeuhey Me&c& Centeh you wehe, on a&~nnaX.i.ngW&A, W&aa S. P&~ce Oh VJL.G. Fhanb 0. Tgm, tihough o&y one 06 these Auhge0n.A opetLcLtedupon you. A dL4advanZageob &iA AyAtm mug be Xhe &AA 06 a c.LoA~ dootah-patient tle..&Cotikip behueenthe ptient and a bingte phybioian. On the 0the.h hand an advantage .i~ dhat wkiee one 06 the docfou may be rxt.&.nding a medicaL mee.&g oh ,&5 unavaieabte 6Oh AOme othen. heabon thme i.b, with hate exception, a bWLgeonau&bee who .ih ,@niC#~ wtih each ptiwu2 i.&WAA, ope4ation, and hodpm COWU~. Thencetie manyotheh bace& blLt we waLLed be tn0A.t
Pleahe
tieheAti?d
.h
g0U.X
heidiOK
ab
a pti&
x0
J%A
AyA.tem.
check one 05 the ,jo&?ow&g: 1 ) no comme&, ( ) fikibedAgAte& (
) dinliked
(
) de& abandoned.
bybtem,
Oh
CUMMEMS:
We w.&? hoed youh hep.tg conbidehed in OWL e66oh& youh coopefui.Cm.
-in Xhe Aticte,4nt to
imphove
con&Ldence. It hea&h
cahe
wi5.Z
detiveny.
be btiwtg Thank you
6oh
SLnceheLy goti, WUm S. Pitice, M.D., F.A.C.S. G. Fhank 0. Tym, M.V., F.R.C.S.(C) Vepahxhent 06 Suhgehy USP/GFOT/ck Fig.
S. Questionnaire
sent to patients
gencies, and patient rounds including applied resident and student teaching. The staff surgeon on research is responsible only
having
open
heart
surgical
procedures,
to his laboratory associates and formal teaching commitments. A weekly period was chosen as this brings both physicians
128
JOURNAL
OF
SURGICAL
RESEARCH,
VOL.
16,
NO.
2,
FEBRUARY
1974
THE MILTON S. HERSHEY MEDICAL CENTER THE PENNSYLVANIA STATE UNIV!ZRSITY
Department of Sqery HERSHEY,
PF.NNSYL.VANIA
17033
717 5344328
PATIENTS
AUhilTTEU
TO THE SERVICE
OF
DR. G. FRANK 0. TYERS AN-V DR. WLLZAM
S.
PIERCE.
bhate hQ.bpOtiib~y i$oh yoWr athe&wnt. &tinaZkg ptiodn to ptient cute and O&y one 06 titie buhgeonb education-hti&eahch obkgatioti . ~hdinahiey w.iU be involved & yowc bwLgiccLe phoceduhe but both may be .invo.k.d ln t&b way, both bWLgeOVIb in youh pJ&? and pobtopUa.tive management. gain 6-g tih you& L&te& and Rhea&en.& b0 ab to bettti abb&t you kt the &&he. D/r.
Each
Phhce
06
and
yaw
Phybitin’b potint
tigh &OS&y b&I&&b
oh.
Tyw
buhgeoti
htiponnibUti ~espotiib.Xity
medic&
q&y h&.&d aMd
and
wiee devotti
ake tkrree-6o1d. The dtif and mabt im~2 Xo provide you, the paaX&, wLth advanced, and bWLgk.& cake. The becond &tipotiibWy &
involvti
the
education
and
by3etlv&ion 06 medical
ti itiuke qtiy rnti cahe doh you and yoti The thLtd henpotiibtiy .ib to conduct &mily now and in the &We. hcAeahe.h ~3 h&p devtiop nw and &phoved methods 06 a?w.aXm&. O&y thhough a Tim appoach can youh phybician’b hope to prrovide you Luith good cahe wkiee cotintig io p~ue nw mtxLica.l hnou.&e.dge a%wugh hCbeahch and attendance at me.&& metingb. hebnident6
16 you have any quentioionn, 06 youh phybiciati. Thank
pLe.abc bhing
thm
~3 the attention
06 one
you.
Fig. 4. Explanation
of practice organization
for cardiothoracic
surgery patients.
into contact with the majority of patients ten explanation shown in Fig. 4 which is admitted to the hospital. given to all patients at the time of admisPatient acceptance has been good. Over sion. Eighty-five percent of the responding patients liked the system enough to supply 50$!6 response was received to an inquiry directed to 80 consecutive patients who had amplification of their support. A perfect open heart surgery following the introducscore is, of course, not possible in the praction of the alternating full time system. tice of medicine, and this type of informaThe questionnaire, sent out approximately tion is not widely available for other prac1 month ago, is shown in Fig. 3. Only 2 tice patterns. patients (2.5%) felt abandoned in this sysResident time has been conserved by tem, and each of these patients had a se- having all patients on any given day the verely complicated administrative or medi- responsibility of only two staff members, cal course which was not the result of the the alternating man or the division chief. alternating practice system. Five percent of Teaching assignments are rarely missed patients did not like the system or did not and emergencies do not interfere with feel that it was adequately explained in ad- preparation. Research productivity has increased significantly with presentations at vance, and we have since prepared the writ-
T1-EHS,
PIEHCE,
AND
W~4LDHAUSES:
national and international meetings now averaging over 5 and publications over 10 per man per year. Research within the cardiothorncic surgical division has been funded by four federal and four state or private grants for total nonuniversity support during the last year of $372,000.00. Over the same period, cardiopulmonary bypass cases increased from 2-3 per week to 5-6 per week, with corresponding increases in closed cardiac and thoracic surgery. The advantages of the alternating week system are outlined in Table 2. A total of 432 thoracic and vascular operations were performed by the two alternating surgeons during the last year. In Table 3 are listed the potential disadvantages of the system. In reference to points 1 and 2, a most sensitive indicator of the depth of a physicians involvement is his willingness to comfort the patients family at the time of a death and to obtain permission for postmortem examinat,ion [ 71. Permission for autopsy examination was obtained in over 75% of patients who died last year, and in well over 75% of cases permission was personally obtained by the staff physician. In reference to point 3, the necessity for referring physicians within the medical center to deal with the senior resident arises from their uncertainty as to which of the staff physicians is on call without consulting the call list. While this may pose a slight inconvenience to t’he referring physician during a period of adjustment, it is more than off-
Table
I. 2.
3. 4.
5.
2. Advantages Periods
of the Alternating Mrthod of Practici
Full-Time
Guaranteed uninterrupted average research t,ime of 30 hr/week h’linimal, if any, loss of clinical income to the department Loss of the disruptive effect of emergency surgery on teaching and research activities Increased role of the resident staff in initial decision making and contact with referring physicians Staff physician familiar with the patient’s problem and previous treatment almost always available
TEACHING-HESEAKCH
Table
129
RESl’ONSIBILITY
S. Disadvantages of the Alternating Periods Method of Practice
Full-Time
1. Some loss of the traditional relat,ionship between an individual doctor and patient 2. Possible decrease in intensit,y of a physicians personal involvement 3. Annoyance to some referring physicians 4. Loss of clinical prestige
set by the increased training provided the resident by seeing the majority of patients prior to staff consultation and decision. Outside physicians generally call the cardiothoracic office and refer their patients without specifying a particular surgeon. With reference to point 4, loss of clinical prestige, one of the participants wive’s reacted to an initial description of the system with, “Well, it’s alright if you don’t want to be a real doctor.” An alternating week surgeon may be compared to a paratrooper who only jumps every other week, and a slightly condescending attitude may be noted on the part of the “real” doctors. However, we believe that by improving the participation of the young academician in teaching and administrative functions and thus his understanding of the workings of his university early in his career and by insuring regular periods of uninterrupted research time, the attractiveness of academic surgery may be increased and the present net yearly loss of academic surgeons slowed or reversed. The system of alternating full time responsibility allows achievement of peak efficiency with a minimum of duplication of effort and is of benefit to house staff, students, and patients, who can count on the uninterrupted attention of one staff member. The potential of this system is especially great for specialty practice in new centers where a small house and teaching staff is faced with a rapidly expanding case load. On the other hand, we feel it would be a mistake to coerce this system upon those to whom it is distasteful. Also, the system, as we use it, may be better suited to a high intensity, relatively low patient
130
.lOURiTAL
OF
SURGICAL
RESEARCH,
volume specialty such as cardiothoracic or neurosurgery and may ofrer no advantage in high volume practices such as otolaryngology and urology. Undoubtedly, other methods of providing protected time for teaching and/or research [2] will also find application. To quote Maloney [7], “The over emphasis on research, the denigration of clinical activities, and the introduction of an elective curriculum have already had measurable effect on the quality of medical education in one school.” Our system is not an attempt to continue this defamation of clinical expertise, but rather to provide each of the facets of the academic surgeons continuum of responsibility, from clinical surgery through research, with proper emphasis and undivided attention during a period of time specifically allotted only to it. An idea without time for demonstration of its value and for persuasion of others to its application is of little value [3.]. Hopefully through protected periods of full time research, surgeons who are actively involved in the practice of medicine may effect earlier transfer of laboratory developments to clinical reality. SUMMARY House staff and medical student teaching, laboratory research, clinical surgery, and university and hospital administrative duties all compete for the academic surgeons time. Teaching, research, and clinical surgery could singularly demand full time,
VOL.
16,
NO.
2,
FEBRUARY
i974
but each supplements the other two in the academic setting. Balance and meaning are lost if one prospers to the detriment of the others,
and
yet,
because
of the
persistent
and non-negotiable demands of clinical practice, teaching, research, and administrative
duties
of necessity
come in a distant
second when competing with patient care responsibilities. The system of alternating full
time
responsibility
allows
achievement
of peak efficiency in both the clinical and research spheres with a minimum of duplication of effort and is of benefit to house staff, students, and patients who can count on the uninterrupted attention of a staff member. REFERENCES 1.
Bunker, J. P. Surgical manpower. A comparison of operations and surgeons in the United States and in England and Wales. New Eng. J. Med. 282:135-144,
1970.
2. Curreri, P. W., and Baxter, C. R. An elective clinical teaching program for first year medical students. J. Surg. Res. 14:114-120, 1973. 3. Dock, W. How the investigative Scot foiled the continental conqueror. Pharos 20:56-58, 1967.
4. Durant,
T. M. Motivation and medicine. 101-106, 1968. 5. Fonkalsrud, E. W. Winds of change in academic surgery. J. &rg. Res. 14:81-86, 1973. 6. Gurd, F. N. The education of the academic surgeon. Ann. R. Coil. Phys. Surg. Can. Pharos
1:284-289,
31:
1968.
7. Ma!oney, J. V. A report on the role of eronomic motivation in the performance of medical school faculty. Surgery 68: 1-19, 1970. 8. Zo!linger, R. M. 9 loser today, a winner tomorrow. Burr. Amel. Coil. isurg. 57:10-16, 1972.