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Black clouds and silver linings
JOURNAL
OF
SIJRGIC.4L
RESEARCH,
11,
258-263
SPecial Article BLACK
CLOUDS AND SILVER W.
GERALD
AUSTEN,
DIFFICULT PROBLEMS confront medicine today, problems perhaps more serious than ever before. Seemingly insoluble, many complicated issues must be resolved, and in my view, these solutions should and must come, in large measure, from the academic community. In this address, I will consider the state of the academic triad: patient care, teaching, and research, and will discuss some of the perplexing questions that exist in these three areas. The day of the ivory tower, at least in medicine, appears to be over. The appeal of research for the sake of research alone has waned. Too many urgent problems clamor for attention now for people to be satisfied with intangible, distant goals. The public demands relevance. Medical service is a national resource financed by the people of this country. Vast sums of money have been and are being appropriated in the interest of a better health program for all. We must, therefore, allow open review of our endeavors and must constantly strive for more efficient means of accomplishing our jobs. Health care delivery is in the focus of national attention. The reasons for this are obvious: our health care system is both outmoded and inefficient. As a country, we have quite correctly said that everyone deserves excellent medical care. The immediate effect of this statement of policy has been that approximately 25 per cent of our country, previously, Presidential Address delivered at the Fourth nual Meeting of the Association for Academic gery, Denver, November 20, 1970. Submitted for publication February 1, 1971.
LININGS
M.D.
at least, partially disenfranchised medically, have, in theory, been added to the patient pool. This change has occurred at a time when the numbers of our medical personnel have not been sufficiently increased to care for the needs of our growing population. Serious personnel problems exist in most medical fields. To mention the most obvious, we have serious shortages of anesthesiologists, radiologists, pathologists, pediatricians, psychiatrists, and primary physicians. Perhaps we have a sufficient number of doctors in certain fields, but it is clear that their distribution is unsatisfactory. Furthermore, we do not have a sufficient number of well-trained individuals. This is certainly true in surgery, as participation in the American Board of Surgery Examination will readily bear out. Approximately 25 per cent of our residencies in surgery are filled by individuals graduating from foreign medical schools. Many of these young men remain in the United States for their lifetimes. Some, indeed, are well trained and have good medical backgrounds, but this is not always the case. There is also the problem of the “brain drain” when these individuals, badly needed in their homelands, choose to remain in the United Stat’es rather than return to their country of origin. To face our community responsibilities, the medical school must play a more active role in the health care of the nation, We cannot t’ake on all of the health care responsibilities for our region. We can, however, be a special resource for the area, and we should be innovative. We must explore new approaches to health care.
AnSur-
258
AUSTEN:
BLACK
CLOUDS
We should test hypotheses and probe for more efficient approaches to various health care problems. I do not know what will be the most cff ect#ivc approach. However, I am certain that innovators, responsive t’o new ideas, will be best qualified to study t’he problems at hand and formulate solutions. A method of efficient separation of the sick from the well is required. One aspect of such separation may be in the use of computers for mass screening. The extensive use of the cornputer in case history taking as well as compiling laboratory data appears promising. Careful studies must be made to determine the value of these methods. Another aspect of the efficient separation of the sick from the well concerns the expansion of better ambulatory care facilities. This is of great importance in the improvement of patient care and the avoidance of unnecessary hospitalization. The regional approach with general care in eatel1it.e clinics and hospitals and specialized care at the medical center has been one of t’he most satisfactory developments in recent years. The regional center itself should serve as the most effective care facility for the complex case. However, one of the problems in delivery of medical care lies in the inability of pat,ients to get, to and from the regional center. Efficient and readily accessible transportation is essential and appropriate helicopter and ambulance services must be developed. The expanded use of modern communication techniques will undoubtedly be helpful in facilitating expert consultation without requiring paticnt transportation. Television and other techniques will also be educationally valuable. Within the hospital setting itself, the delircry of health care must be much more efficient in yrars to come. It should bc pointed out that, although some urban hospitals are utilized at essentially maximum patient capacity or greater, many other hospitals are utilized at far less than complete potential. These differcnccs in distribution causes considerable ineffiriences. Furthcrmorc, at present, adequate low cost extended care facilities are not available; WCneed these resources to remove appropriate patients from the high cost, acute care hospital. A more businesslike approach in the hospital is necessary, yet we must work out
AND
SILVER
LINIKGS
259
ways to avoid dehumanizing the hospital experience. Of top priority is the need to improve t’he efficiency of the physician and of the nurse. Their skills are resources that are scarce and cannot easily be duplicated. Many hospitals have begun computer programs to improve record keeping and data collection. These are basic approaches that require careful scrutiny and further experimentat’ion. Pertinent information in a patient’s medical history should be readily available through computer techniques. This information should be available not only in evaluating the patient’s present acute illness, but also in summarizing previous problems. However, the expense of these “efficiency measures” require scholarly study to determine their value. The expanded use of paramedical personnel is essential to our present and future health care delivery system. We need these paramedical personnel to improve patient care and to improve the efficiency of the doctor and the nurse. If properly trained and supervised, assistants and technicians will be able to make an enormous contribution to our health care system. We must carefully plan their educat’ional program; we must define their duties; we must structure their rewards toward growth and upward mobility. In our wish to improve health care, we must keep in mind the major health problems as yet unsolved today. In addition to expanding and improving general medical care, WC must face such problems as the delivery of medical care to the poor, the treatment of chronic terminal illness, the care of the aged, the treatment of venereal disease, the problem of abortion on demand, the care of psychiatric patients, and the treatment of drug addiction and alcoholism. Many of these problems are not surgical, but all of us in medicine must assume responsibility in confronting these common problems and in solving them together. .Juat’ as we have a role in improving surgical ambulatory and in-hospital patient care and in bringing sophisticated medicine to every citizen, so should we, as responsible members of the medical community, also assume our obligations to help ameliorate these other medical problems. We must all look ahead and, for a change, really plan for t’he future. What’ kind of health
260
JOURNAL
OF
SURGICAL
RESEARCH,
care system do we want ten years from now? As the innovators, we have the opportunity and the obligation to make changes based on clinical trial that will determine the health care system in the future. Let me emphasize that our efforts to improve health care delivery need not be accomplished to the exclusion of laboratory and clinical investigation. Laboratory and clinical research is essential for a balanced, modern approach to disease; unless we continue to undertake research programs as well as to make progress in health care delivery, we will not be able to offer t’he best health care in the years to come. The second part of the academic triad concerns medical education. Essentially every enormous medical school has undergone changes in its educational programs during the past few years. These changes were long overdue; most of us applaud the direction that they have t’aken. We have made the medical school program much more flexible ; the student has a greater opportunity to decide the kinds of information that he feels will be important for his future career. We realize that we cannot teach everything in depth to every student and have agreed that t’he ultimately different goals of individual students may dictate different experiences during the medical school program. We must and are extending this philosophy to the admission committees of our medical schools. In the past, we have, in a sense, defined the types of individuals that we expected to graduate from medical school. For example, we placed an enormous weight on an individual’s performance in some undergraduate courses such as organic chemistry and biochemistry. I do not quibble with this approach in many circumstances. However, it does seem clear that if we apply the same yardstick to everyone entering medical school, we should not be surprised to have an overabundance of personnel in certain fields and a serious lack in others. Our admission committees have done an excellent job, but they should and, in actual fact, are now expanding their horizons and are picking a wider range of outstanding candidates: many who, as previously, show great promise in biochemistry and physiology but also some who show particular promise in
VOL.
11,
NO.
5,
MAY
1971
economics, or philosophy, or engineering, or physics, to name just a few. In postgraduate education too, many important changes are in progress. At this level of education, where increased specialization in all areas is occurring, we should be more creative in our planning, and we must strive to be more efficient educationally. Figure 1 illustrates a study by Cope [l] on the years of preparation beyond high school and shows the length of the surgical training program at the Massachusetts General Hospital as it evolved up to 1950. It was projected at that time that, should the length of training in surgery continue to increase at the same rate, t’he training program would take approximately 18 years by 1970. It is interesting from the vantage point of 1970, that 4 years of college, 4 years of medical school, 5 years of internship and residency, 2 years of military service and 2 years of postgraduate basic science, elected by some of our academically oriented young men, comes very close to the previous projection as regards length of training. The time has certainly come to evaluate our t.raining programs and determine the requirements of training relative to desired goals. The significance of this becomes even more important as we consider the increasing amount of knowledge required in specific fields and the increasing need for the individual pursuing an academic surgical career to have experience in basic research. It is a pleasure t’o not’e the move in many schooIs to shorten the length of time in medical school and to try in every conceivable way to shorten the training period. I would, however, like to give one word of caution. As we shorten the medical school experience and also consider shortening the postgraduate clinical training, we must be certain that each trainee receives a sufficient amount of broad clinical experience. It is no wonder that a reevaluation of our educational concepts has occurred in many surgical programs. Great service needs, existing in all of the clinical areas, make immediate and overwhelming demands. Perhaps, in yielding to the urgency of these needs, we have overemphasized service to the detriment of training. We have not sufficiently delineated the nature of our endeavors in postgraduate
AUSTEN:
BLACK
CLOUDS
AND
SILVER
261
LININGS
AYaEGRiFGE 30.5
8 6
'. ?Cl
Fig. 1. The ye:trs of sttltly
so
hryo~~d high school
lQn(-)
. I I ( ., ,. , ..; j, \';,,.'.,_ .. ~: I I '.a ., IO
for trainees
education. John Kirklin, ic1. D. [2] recently pointed out that our decision regarding the number of our trainees should bc based upon educational opportunities and national needs. Too frcqucntly, the decision regarding numbers of trainees is made on the basis of individual hospital scrvicc needs. The appropriate, expanded use of paramedical personnel may help to lcsscn this problem. I would like to use thoracic surgery to illustrate HO~C of my thoughts regarding a flexible and efficient, yet broad postgraduate training program. I believe that a broad experience in general and cardiothoracic surgery is desirable. It would be unfortunate for cardiothoracic surgery to lose its close relationship to traditional general surgery ; these fields have been and should continue to be closely interrelated. However, in the matt’er of education, it is imperative that we be more efficient in both general and cardiothoracic surgery. It should be possible for the individual desiring to concentrat’e on cardiothoracic surgery to train properly in less time than we now usually require of him, Every surgeon must bc trained to take care of the “whole patient” and should have a proper experience in surgical technique. A considerable amount of general surgical back-
20
30
ill the sllryical
'0
1
1950 6o pr~qqmn
70
at the M.(:.H.,
1850 to 1950.
ground is desirable, and necessary but, depending on the needs of the specific trainee, the full time required for a standard general surgical program may not be an essential prerequisite for every cardiothoracic surgeon. As regards specific thoracic experience, individuals who wish to go directly into the clinical practice of thoracic surgery in the community should be given a balanced experience in cardiac, pulmonary, and esophageal surgery, a program best’ designed to help them meet their clinical responsibilities in practice. Highly qualified individuals, who plan academic careers, should be able to undertake a year or two of research experience and still complete a training program especially tailored to their needs in the same amount of time, or only slightly more, than we now require without t’his research experience. Increasing regionalization of medical care may result in an imbalance in t,he clinical experience in the several areas of thoracic surgery available at many training centers. Therefore, among thoracic training programs in a given area, the utmost cooperation should be extended between the centers to provide an appropriate balance of experiecne in pulmonary, cardiac, and esophageal surgery. As an example, a given program
262
JOURNAL
OF
SURGICAL
RESEARCH,
may offer an excellent course in general thoracic surgery but lack adequate material for training a man in cardiac surgery ; or the reverse may be true. Under such limitations, the trainee should be helped in his quest for a balanced experience, including the supplementation of his training at more than one center. In addition, individuals may vary in their training needs as to the length of time required to achieve competence in thoracic surgery, some requiring more and some less. In this respect, the emphasis on the rigid a-year straight thoracic program may, in some ways, be unfortunate. The ultimate goal is the most efficient training of the best cardiothoracic surgeons. Therefore, there should be maximum flexibility in the duration and content of thoracic training. It would seem reasonable to entrust considerable discretionary authority in the Chiefs of the Training Programs. The preservation of independent responsibility of the trainee is highly significant in the structure of postgraduate programs in surgery.
National Health Care
0.11 ' 1956
'
'
' ' 1960
'
'
'
' ' 1965
'
'
'
1 1970
YEAR Fig. 2. Money spent for federally supported biomedical research as compared to GNP, Federal Budget, and National Health Care from 1956 to 1970. Illustration supplied by AAMC. Source GNP, Office of Business Economics. Federal Budget, U. S. Office of Management and Budget. National Health Care, NIHOPPE-Office of Resources Analysis.
VOL.
11,
NO.
5,
M.4Y
1971
The recent changes in health financing have put major pressures on retaining this independence and pose a serious threat to a very intrinsic part of surgical education. The issue is crucial: will we continue to have our trainees assume independent responsibility and authority? The line between proper support and education of our trainees with appropriate protection of the patient and oversupervision of our trainees is a very fine one. Too much supervision may result in inferior training and insufficient confidence on t’he part of the trainee. As the hospital setting responds to changes resulting from the social and economic pressures of our time, we must be careful not to lose this crucial aspect of surgical education. Part of our task as educators is to acquaint our trainees with the unique problems facing medicine today. Their understanding must encompass not only a knowledge of diseases and treatment of them, but also an awareness of the social, economic, and political problems that relate to these diseases. Academic knowledge and perfect technical skill are, of course, essential for the successful completion of, for example, a heart transplant operation, but t’hey are not enough. The trainee must also understand something of the financial burden of this procedure on the patient, his family, and the taxpayer, and he should be aware of the alternatives in the way in which these resources could be used for the public good. We need to treat each trainee as an individual seeking to develop his greatest potential in the field of his choice. We need to be flexible and understanding in our presentation of various opportunities in the field of medicine and to help each trainee obtain the best education in the least possible time. This can be achieved best by (1) maintaining a balanced program of varied clinical material, (2) having a flexible program, keeping in mind the background of each candidate as well as his ultimate goals, (3) insuring a sufficient amount of basic education, without requirement of unnecessary experiences, so that a trainee can properly handle his chosen area of interest, and (4) participating in career planning by permitting relevant and broad experiences and by giving objective, unprejudicial advice.
AUSTEN:
BLACK
CLOUDS
The t,hird area of the triad, research, must be considered in connection with the problems of funding biomedical research and education. Figure 2 demonstrates what has happened in recent years. The situation is quite straightforward. The biomedical community has enjoyed a 20-year period of unparalleled growth. The last few years, however, and probably the future will be very different. The biomedical research community will have to prove that they tleserve the funding that they receive. They will be in competition with all of the other pressing needs of the country: defense, urban problems, the fight against pollution to name just, :I few. It is fair and just that t’his be the case. However, if medicine will work to prove its point, it has a very potent argument. me need more biomedical research. If we draw on the past, we can prorc the benefits of previous funding in the biomedical research area t,o the health and happiness of the country and can, as a matter of fact, show a very favorable cost-effectiveness ratio. The control of poliomyelitis is an excellent example. The monetary cost of caring for a few thousand severely disabled poliomyelitis victims can be translated into a large port#ion of the yearly NIH budget, and this does not even begin to take into account the matter of happiness, the saving of lives, the gain in wages, and other meaningful personal factors. Cogent defense may also be made with many other medical breakthroughs such as the control of infect’ions with antibiotics, the lower incidence of tuberculosis along with advances in the methods of treatment, and marked improvement in results associated with essentially all surgical procedures, due to research in anesthesia, surgical technique, cardiopulmonary physiology and postoperative intensive care, etc. Our educational needs in medicine must also be advanced with compelling arguments. Educational and biomedical research needs are obvious to us, but they are not so obvious to Congress nor to the Executive Branch. Neither are t’hey completely clear to our fellow citi-
AND
SILVER
LININGS
263
zens. Once again, we have a good case, but the story needs to be told. Pertinent, too, is the need for dedicated medical scientists and teachers. Because we will have to fight for our research and educational needs and because we will undoubtedly be rebuffed at times, it is more important than ever to have young men in academic life who really care about teaching and research and who will not be discouraged by temporary setbacks. In this address, I have made an attempt to touch 011 a number of the problem areas of medicine t,hat face us today. The solutions of these problems arc vital. As young people in academic surgery, we will have to live with the medicine of the future; we should not allow the decisions for the future to bc made solely by others. We should become knowledgeable about these problems, and we must participate in innovative studies to determine new and fruitful approaches to these problems and their ultimate solutions. Finally, although we are encountering dark clouds, problems that require constructive solutions, we should not’ feel gloomy about our situation. Unlike some of the other professional fields such as engineering, physics, or chemistry in which as many as 20 per cent of the people in some areas of our country are presently uncmploycd, medicine appears to be “depression proof.” We arc very much needed. No one need worry about being out of work in medicine, with t,he exceptions, of course, of deans and department’al chairmen! We are extraordinarily lucky in medicine. We are needed, and we have an enormous opportunity to be imaginative in the improvement of medical education, research, and patient care for the future. I am hopeful that there are silver linings ahead. REFERENCES 1. Cope, Oliver. The Endicott House Conference. In John Knowles (Ed.), Views of Medical Education and Medical Cure, pp. 139-169. Cambridge: Harvard Univ. Press,1968. 2. Kirlrlin, John. Personal communication.
OF
SIJRGIC.4L
RESEARCH,
11,
258-263
SPecial Article BLACK
CLOUDS AND SILVER W.
GERALD
AUSTEN,
DIFFICULT PROBLEMS confront medicine today, problems perhaps more serious than ever before. Seemingly insoluble, many complicated issues must be resolved, and in my view, these solutions should and must come, in large measure, from the academic community. In this address, I will consider the state of the academic triad: patient care, teaching, and research, and will discuss some of the perplexing questions that exist in these three areas. The day of the ivory tower, at least in medicine, appears to be over. The appeal of research for the sake of research alone has waned. Too many urgent problems clamor for attention now for people to be satisfied with intangible, distant goals. The public demands relevance. Medical service is a national resource financed by the people of this country. Vast sums of money have been and are being appropriated in the interest of a better health program for all. We must, therefore, allow open review of our endeavors and must constantly strive for more efficient means of accomplishing our jobs. Health care delivery is in the focus of national attention. The reasons for this are obvious: our health care system is both outmoded and inefficient. As a country, we have quite correctly said that everyone deserves excellent medical care. The immediate effect of this statement of policy has been that approximately 25 per cent of our country, previously, Presidential Address delivered at the Fourth nual Meeting of the Association for Academic gery, Denver, November 20, 1970. Submitted for publication February 1, 1971.
LININGS
M.D.
at least, partially disenfranchised medically, have, in theory, been added to the patient pool. This change has occurred at a time when the numbers of our medical personnel have not been sufficiently increased to care for the needs of our growing population. Serious personnel problems exist in most medical fields. To mention the most obvious, we have serious shortages of anesthesiologists, radiologists, pathologists, pediatricians, psychiatrists, and primary physicians. Perhaps we have a sufficient number of doctors in certain fields, but it is clear that their distribution is unsatisfactory. Furthermore, we do not have a sufficient number of well-trained individuals. This is certainly true in surgery, as participation in the American Board of Surgery Examination will readily bear out. Approximately 25 per cent of our residencies in surgery are filled by individuals graduating from foreign medical schools. Many of these young men remain in the United States for their lifetimes. Some, indeed, are well trained and have good medical backgrounds, but this is not always the case. There is also the problem of the “brain drain” when these individuals, badly needed in their homelands, choose to remain in the United Stat’es rather than return to their country of origin. To face our community responsibilities, the medical school must play a more active role in the health care of the nation, We cannot t’ake on all of the health care responsibilities for our region. We can, however, be a special resource for the area, and we should be innovative. We must explore new approaches to health care.
AnSur-
258
AUSTEN:
BLACK
CLOUDS
We should test hypotheses and probe for more efficient approaches to various health care problems. I do not know what will be the most cff ect#ivc approach. However, I am certain that innovators, responsive t’o new ideas, will be best qualified to study t’he problems at hand and formulate solutions. A method of efficient separation of the sick from the well is required. One aspect of such separation may be in the use of computers for mass screening. The extensive use of the cornputer in case history taking as well as compiling laboratory data appears promising. Careful studies must be made to determine the value of these methods. Another aspect of the efficient separation of the sick from the well concerns the expansion of better ambulatory care facilities. This is of great importance in the improvement of patient care and the avoidance of unnecessary hospitalization. The regional approach with general care in eatel1it.e clinics and hospitals and specialized care at the medical center has been one of t’he most satisfactory developments in recent years. The regional center itself should serve as the most effective care facility for the complex case. However, one of the problems in delivery of medical care lies in the inability of pat,ients to get, to and from the regional center. Efficient and readily accessible transportation is essential and appropriate helicopter and ambulance services must be developed. The expanded use of modern communication techniques will undoubtedly be helpful in facilitating expert consultation without requiring paticnt transportation. Television and other techniques will also be educationally valuable. Within the hospital setting itself, the delircry of health care must be much more efficient in yrars to come. It should bc pointed out that, although some urban hospitals are utilized at essentially maximum patient capacity or greater, many other hospitals are utilized at far less than complete potential. These differcnccs in distribution causes considerable ineffiriences. Furthcrmorc, at present, adequate low cost extended care facilities are not available; WCneed these resources to remove appropriate patients from the high cost, acute care hospital. A more businesslike approach in the hospital is necessary, yet we must work out
AND
SILVER
LINIKGS
259
ways to avoid dehumanizing the hospital experience. Of top priority is the need to improve t’he efficiency of the physician and of the nurse. Their skills are resources that are scarce and cannot easily be duplicated. Many hospitals have begun computer programs to improve record keeping and data collection. These are basic approaches that require careful scrutiny and further experimentat’ion. Pertinent information in a patient’s medical history should be readily available through computer techniques. This information should be available not only in evaluating the patient’s present acute illness, but also in summarizing previous problems. However, the expense of these “efficiency measures” require scholarly study to determine their value. The expanded use of paramedical personnel is essential to our present and future health care delivery system. We need these paramedical personnel to improve patient care and to improve the efficiency of the doctor and the nurse. If properly trained and supervised, assistants and technicians will be able to make an enormous contribution to our health care system. We must carefully plan their educat’ional program; we must define their duties; we must structure their rewards toward growth and upward mobility. In our wish to improve health care, we must keep in mind the major health problems as yet unsolved today. In addition to expanding and improving general medical care, WC must face such problems as the delivery of medical care to the poor, the treatment of chronic terminal illness, the care of the aged, the treatment of venereal disease, the problem of abortion on demand, the care of psychiatric patients, and the treatment of drug addiction and alcoholism. Many of these problems are not surgical, but all of us in medicine must assume responsibility in confronting these common problems and in solving them together. .Juat’ as we have a role in improving surgical ambulatory and in-hospital patient care and in bringing sophisticated medicine to every citizen, so should we, as responsible members of the medical community, also assume our obligations to help ameliorate these other medical problems. We must all look ahead and, for a change, really plan for t’he future. What’ kind of health
260
JOURNAL
OF
SURGICAL
RESEARCH,
care system do we want ten years from now? As the innovators, we have the opportunity and the obligation to make changes based on clinical trial that will determine the health care system in the future. Let me emphasize that our efforts to improve health care delivery need not be accomplished to the exclusion of laboratory and clinical investigation. Laboratory and clinical research is essential for a balanced, modern approach to disease; unless we continue to undertake research programs as well as to make progress in health care delivery, we will not be able to offer t’he best health care in the years to come. The second part of the academic triad concerns medical education. Essentially every enormous medical school has undergone changes in its educational programs during the past few years. These changes were long overdue; most of us applaud the direction that they have t’aken. We have made the medical school program much more flexible ; the student has a greater opportunity to decide the kinds of information that he feels will be important for his future career. We realize that we cannot teach everything in depth to every student and have agreed that t’he ultimately different goals of individual students may dictate different experiences during the medical school program. We must and are extending this philosophy to the admission committees of our medical schools. In the past, we have, in a sense, defined the types of individuals that we expected to graduate from medical school. For example, we placed an enormous weight on an individual’s performance in some undergraduate courses such as organic chemistry and biochemistry. I do not quibble with this approach in many circumstances. However, it does seem clear that if we apply the same yardstick to everyone entering medical school, we should not be surprised to have an overabundance of personnel in certain fields and a serious lack in others. Our admission committees have done an excellent job, but they should and, in actual fact, are now expanding their horizons and are picking a wider range of outstanding candidates: many who, as previously, show great promise in biochemistry and physiology but also some who show particular promise in
VOL.
11,
NO.
5,
MAY
1971
economics, or philosophy, or engineering, or physics, to name just a few. In postgraduate education too, many important changes are in progress. At this level of education, where increased specialization in all areas is occurring, we should be more creative in our planning, and we must strive to be more efficient educationally. Figure 1 illustrates a study by Cope [l] on the years of preparation beyond high school and shows the length of the surgical training program at the Massachusetts General Hospital as it evolved up to 1950. It was projected at that time that, should the length of training in surgery continue to increase at the same rate, t’he training program would take approximately 18 years by 1970. It is interesting from the vantage point of 1970, that 4 years of college, 4 years of medical school, 5 years of internship and residency, 2 years of military service and 2 years of postgraduate basic science, elected by some of our academically oriented young men, comes very close to the previous projection as regards length of training. The time has certainly come to evaluate our t.raining programs and determine the requirements of training relative to desired goals. The significance of this becomes even more important as we consider the increasing amount of knowledge required in specific fields and the increasing need for the individual pursuing an academic surgical career to have experience in basic research. It is a pleasure t’o not’e the move in many schooIs to shorten the length of time in medical school and to try in every conceivable way to shorten the training period. I would, however, like to give one word of caution. As we shorten the medical school experience and also consider shortening the postgraduate clinical training, we must be certain that each trainee receives a sufficient amount of broad clinical experience. It is no wonder that a reevaluation of our educational concepts has occurred in many surgical programs. Great service needs, existing in all of the clinical areas, make immediate and overwhelming demands. Perhaps, in yielding to the urgency of these needs, we have overemphasized service to the detriment of training. We have not sufficiently delineated the nature of our endeavors in postgraduate
AUSTEN:
BLACK
CLOUDS
AND
SILVER
261
LININGS
AYaEGRiFGE 30.5
8 6
'. ?Cl
Fig. 1. The ye:trs of sttltly
so
hryo~~d high school
lQn(-)
. I I ( ., ,. , ..; j, \';,,.'.,_ .. ~: I I '.a ., IO
for trainees
education. John Kirklin, ic1. D. [2] recently pointed out that our decision regarding the number of our trainees should bc based upon educational opportunities and national needs. Too frcqucntly, the decision regarding numbers of trainees is made on the basis of individual hospital scrvicc needs. The appropriate, expanded use of paramedical personnel may help to lcsscn this problem. I would like to use thoracic surgery to illustrate HO~C of my thoughts regarding a flexible and efficient, yet broad postgraduate training program. I believe that a broad experience in general and cardiothoracic surgery is desirable. It would be unfortunate for cardiothoracic surgery to lose its close relationship to traditional general surgery ; these fields have been and should continue to be closely interrelated. However, in the matt’er of education, it is imperative that we be more efficient in both general and cardiothoracic surgery. It should be possible for the individual desiring to concentrat’e on cardiothoracic surgery to train properly in less time than we now usually require of him, Every surgeon must bc trained to take care of the “whole patient” and should have a proper experience in surgical technique. A considerable amount of general surgical back-
20
30
ill the sllryical
'0
1
1950 6o pr~qqmn
70
at the M.(:.H.,
1850 to 1950.
ground is desirable, and necessary but, depending on the needs of the specific trainee, the full time required for a standard general surgical program may not be an essential prerequisite for every cardiothoracic surgeon. As regards specific thoracic experience, individuals who wish to go directly into the clinical practice of thoracic surgery in the community should be given a balanced experience in cardiac, pulmonary, and esophageal surgery, a program best’ designed to help them meet their clinical responsibilities in practice. Highly qualified individuals, who plan academic careers, should be able to undertake a year or two of research experience and still complete a training program especially tailored to their needs in the same amount of time, or only slightly more, than we now require without t’his research experience. Increasing regionalization of medical care may result in an imbalance in t,he clinical experience in the several areas of thoracic surgery available at many training centers. Therefore, among thoracic training programs in a given area, the utmost cooperation should be extended between the centers to provide an appropriate balance of experiecne in pulmonary, cardiac, and esophageal surgery. As an example, a given program
262
JOURNAL
OF
SURGICAL
RESEARCH,
may offer an excellent course in general thoracic surgery but lack adequate material for training a man in cardiac surgery ; or the reverse may be true. Under such limitations, the trainee should be helped in his quest for a balanced experience, including the supplementation of his training at more than one center. In addition, individuals may vary in their training needs as to the length of time required to achieve competence in thoracic surgery, some requiring more and some less. In this respect, the emphasis on the rigid a-year straight thoracic program may, in some ways, be unfortunate. The ultimate goal is the most efficient training of the best cardiothoracic surgeons. Therefore, there should be maximum flexibility in the duration and content of thoracic training. It would seem reasonable to entrust considerable discretionary authority in the Chiefs of the Training Programs. The preservation of independent responsibility of the trainee is highly significant in the structure of postgraduate programs in surgery.
National Health Care
0.11 ' 1956
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' ' 1960
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' ' 1965
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1 1970
YEAR Fig. 2. Money spent for federally supported biomedical research as compared to GNP, Federal Budget, and National Health Care from 1956 to 1970. Illustration supplied by AAMC. Source GNP, Office of Business Economics. Federal Budget, U. S. Office of Management and Budget. National Health Care, NIHOPPE-Office of Resources Analysis.
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The recent changes in health financing have put major pressures on retaining this independence and pose a serious threat to a very intrinsic part of surgical education. The issue is crucial: will we continue to have our trainees assume independent responsibility and authority? The line between proper support and education of our trainees with appropriate protection of the patient and oversupervision of our trainees is a very fine one. Too much supervision may result in inferior training and insufficient confidence on t’he part of the trainee. As the hospital setting responds to changes resulting from the social and economic pressures of our time, we must be careful not to lose this crucial aspect of surgical education. Part of our task as educators is to acquaint our trainees with the unique problems facing medicine today. Their understanding must encompass not only a knowledge of diseases and treatment of them, but also an awareness of the social, economic, and political problems that relate to these diseases. Academic knowledge and perfect technical skill are, of course, essential for the successful completion of, for example, a heart transplant operation, but t’hey are not enough. The trainee must also understand something of the financial burden of this procedure on the patient, his family, and the taxpayer, and he should be aware of the alternatives in the way in which these resources could be used for the public good. We need to treat each trainee as an individual seeking to develop his greatest potential in the field of his choice. We need to be flexible and understanding in our presentation of various opportunities in the field of medicine and to help each trainee obtain the best education in the least possible time. This can be achieved best by (1) maintaining a balanced program of varied clinical material, (2) having a flexible program, keeping in mind the background of each candidate as well as his ultimate goals, (3) insuring a sufficient amount of basic education, without requirement of unnecessary experiences, so that a trainee can properly handle his chosen area of interest, and (4) participating in career planning by permitting relevant and broad experiences and by giving objective, unprejudicial advice.
AUSTEN:
BLACK
CLOUDS
The t,hird area of the triad, research, must be considered in connection with the problems of funding biomedical research and education. Figure 2 demonstrates what has happened in recent years. The situation is quite straightforward. The biomedical community has enjoyed a 20-year period of unparalleled growth. The last few years, however, and probably the future will be very different. The biomedical research community will have to prove that they tleserve the funding that they receive. They will be in competition with all of the other pressing needs of the country: defense, urban problems, the fight against pollution to name just, :I few. It is fair and just that t’his be the case. However, if medicine will work to prove its point, it has a very potent argument. me need more biomedical research. If we draw on the past, we can prorc the benefits of previous funding in the biomedical research area t,o the health and happiness of the country and can, as a matter of fact, show a very favorable cost-effectiveness ratio. The control of poliomyelitis is an excellent example. The monetary cost of caring for a few thousand severely disabled poliomyelitis victims can be translated into a large port#ion of the yearly NIH budget, and this does not even begin to take into account the matter of happiness, the saving of lives, the gain in wages, and other meaningful personal factors. Cogent defense may also be made with many other medical breakthroughs such as the control of infect’ions with antibiotics, the lower incidence of tuberculosis along with advances in the methods of treatment, and marked improvement in results associated with essentially all surgical procedures, due to research in anesthesia, surgical technique, cardiopulmonary physiology and postoperative intensive care, etc. Our educational needs in medicine must also be advanced with compelling arguments. Educational and biomedical research needs are obvious to us, but they are not so obvious to Congress nor to the Executive Branch. Neither are t’hey completely clear to our fellow citi-
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zens. Once again, we have a good case, but the story needs to be told. Pertinent, too, is the need for dedicated medical scientists and teachers. Because we will have to fight for our research and educational needs and because we will undoubtedly be rebuffed at times, it is more important than ever to have young men in academic life who really care about teaching and research and who will not be discouraged by temporary setbacks. In this address, I have made an attempt to touch 011 a number of the problem areas of medicine t,hat face us today. The solutions of these problems arc vital. As young people in academic surgery, we will have to live with the medicine of the future; we should not allow the decisions for the future to bc made solely by others. We should become knowledgeable about these problems, and we must participate in innovative studies to determine new and fruitful approaches to these problems and their ultimate solutions. Finally, although we are encountering dark clouds, problems that require constructive solutions, we should not’ feel gloomy about our situation. Unlike some of the other professional fields such as engineering, physics, or chemistry in which as many as 20 per cent of the people in some areas of our country are presently uncmploycd, medicine appears to be “depression proof.” We arc very much needed. No one need worry about being out of work in medicine, with t,he exceptions, of course, of deans and department’al chairmen! We are extraordinarily lucky in medicine. We are needed, and we have an enormous opportunity to be imaginative in the improvement of medical education, research, and patient care for the future. I am hopeful that there are silver linings ahead. REFERENCES 1. Cope, Oliver. The Endicott House Conference. In John Knowles (Ed.), Views of Medical Education and Medical Cure, pp. 139-169. Cambridge: Harvard Univ. Press,1968. 2. Kirlrlin, John. Personal communication.