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Education of the surgical specialist
PRESIDENTIAL ADDRESS-AMERICAN SOCIETY FOR SURGERY OF THE HAND
Education of the surgical specialist Richard J. Smith, M.D., Boston, Mass.
In
June of 1982, 16,000 American men and women completed one of the world's most competitive and difficult educational experiences. They were graduated from medical school. By now, almost all of them have been licensed to begin private practice, yet few will do so since most will agree with their deans that they are not prepared to treat patients. 1 Medical school has provided only the foundations in basic science and clinical skills. The recent graduates will need to take a postgraduate residency in order to become competent clinicians. Of the 16,000 graduates, 6700 will become residents in one of the surgical specialties. 2. 3 After several more years of study and work, now older and more deeply in debt, they finally will become surgical specialists. 4 • 5 But despite the lofty and dizzying heights of chief residency, many will decide to go still further and will seek a fellowship. 6-8 If these superspecialists expect to hear enthusiastic cheers of support from those who admire their commitment to scholarship and science, they will be disappointed. Colleagues will accuse them of separating themselves from the substance of medicine-treating the "whole person. " Wives or husbands will complain of the prospect of more years of meager incomes and oppressive night-call schedules. In-laws, who long ago concluded that the marriage was a terrible mistake, will now be convinced that these aging students have no intention of ever becoming "real doctors. " Educating surgical specialists, superannuated scholars now in their tenth year of professional study, is a major responsibility. But whose responsibility is it? Presidential address to the Thirty-eighth Annual Meeting· of the American Society for Surgery of the Hand, Anaheim, Calif., March 8, 1983. Received for publication April 25, 1983; accepted in revised form April 29, 1983. Reprint requests: Richard J. Smith, M.D., Massachusetts General Hospital, ACC427, Boston, MA 02114.
Does it fall to the universities and medical schools or to the government? Are those who practice a profession best able to teach it? And who should monitor this process? Perhaps a glimpse into the past and a look at today's challenges may help us to answer some of these questions. History of surgical education
Specialization developed soon after the ongm of medicine itself. The son of Apollo, god of medicine, was the physician Aesculapius. As Aesculapius was half mortal and half god, he seems to have served as a role model for some of our surgeons today. Before he was struck down by a thunderbolt, bringing a premature end to a very promising medical career, he had a large and scholarly family. His sons Machaon and Podalirios became patron gods of surgery and medicine; his daughters Panacea and Hygeia were identified with pharmacology and public health. 9 Thus it took only three generations before specialists appeared on Mount Olympus. The prestige of this medical dynasty was not to be rivaled until the appearance of the Warrens in Boston and the Mayos in Minnesota many centuries later. From 600 to 400 BC temples of medicine were built throughout Greece.tO Each was like a health spa and religious shrine combined, where patients with obscure internal diseases consulted sacred physicians. Cure was a subject of divine jurisdiction. Such problems as fractures, dislocations, and wounds, however, were treated by the technical doctors-the "techniatrike "-the surgeons. Unlike physicians, surgeons were not sacred. Their social position was somewhat above that of manual worker but not nearly as celestial as that of the physician. 11 This social and professional separation of physician and surgeon was to set a recurring theme. The rift was partially bridged in the fourth century BC when informal associations were developed. throughout Greece where THE JOURNAL OF HAND SURGERY
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Fig. I. In the Twin Temples of Kom Ombro, this hieroglyphic, from 100 BC, shows scalpels, retractors, scissors, trephines, and other instruments used by surgeons at that time.
doctors would teach and practice medicine. The most influential school was that of Hippocrates at Cos. There, lectures were given that covered the fields of surgery, medicine, and ethics. Students were taught at the bedside of patients, and doctors bore the credit or responsibility for the outcome of their treatment. In 300 BC a medical school was built in Alexandria. There, for the first time, human dissection was permitted and demonstrated. Anatomic studies led to rapid advances in understanding disease and deformity, and Alexandria soon became the center of the medical world. Hieroglyphics still can be seen at the temple of Kom Ombro; these show the scalpels, scissors, probes, and retractors used by surgeons in 100 BC (Fig. 1). In Rome, a principal preoccupation of the emperors was war. Thus it is not surprising that the focus of medical education was the treatment of war wounds, and surgeons were preeminent in the medical hierarchy. Celsus (30 AD) described the surgeon as "a peculiar sort of physician who should have special education from childhood onward." Virtually no attention was
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paid to research. Technical competence was the goal of medical education, and there was little progress in the understanding of disease. From Egypt and Rome, the medical spotlight then turned east, and the result was to influence medical education for centuries. Galen was born in Pergamum (Asia Minor) in 130 AD. Since human dissection was no longer practiced, he was handicapped by an inaccurate appreciation of human structure and function,12 yet for 1200 years, his books were never questioned throughout Europe. What he wrote was considered fact. Anatomic and physiologic inquiries ceased completely, and Europe passed into the Dark Ages of medicine. There were no dissections; there were no hospitals; there was no medical inquiry or research. In Islam, however, things were different. 13 Libraries flourished. The first hospital was built in Baghdad in 800 AD, and specialization was encouraged. In order to maintain high levels of medical care, all physicians of Baghdad were required to take and pass an examination before being permitted to practice in their field. These were the first boards and the first medical licenses. In Europe, education of the surgeon was officially separated from that of the physician by a decree of the Lateran Council of 1215 that ruled that surgery and cautery could not be practiced by those belonging to several major ecclesiastic orders. 14 As a result, surgeons could no longer work in church-dominated universities such as those of Oxford, Cambridge, and Paris. Thereafter, surgery was taught predominantly through apprenticeship, and there was little academic control over what was taught and what was learned. In an effort to improve the quality of surgical education, the surgeons took it upon themselves to qualify students. In Great Britain, for example, they formed a Surgeons' Company and set high standards of ethics and competence for membership. Applicants were judged on their manual dexterity and on their ability to pass rigorous examinations covering all branches of medicine and surgery. But the Surgeons' Company had no legal control over those who could practice in their field. When, in 1462, King Edward IV granted a charter authorizing barbers to practice surgery, the prestige of the surgeons slipped considerably. The well-educated, skillful surgeons and the "barber-surgeons" treated similar problems. By contrast, the physicians were more carefully regulated. According to the Medical Acts of 1511 and 1522 in England, only those who passed examinations regulated by the College of Physicians could practice medicine. Thereafter, surgeons in Britain were addressed as "mister" even if they had a university degree.
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The separation of surgeons from barbers paralleled advances in the study of human anatomy. 15 In 1543, Vesailius published the anatomic text, De Humani Corporis Fabrica. Many of his findings and illustrations disagreed with the suppositions of Galen and Avicenna. The public anatomic demonstrations by Vesailius were extremely popular and well attended. Anatomy, and with it surgery, became the first scientifically oriented medical discipline of the Renaissance. 16 In 1745, William Cheselden established a Surgeons' Hall for Anatomic Dissection in London. Barbers were excluded. Soon other anatomy amphitheaters were built as adjuncts to voluntary hospitals where students served several years as surgical apprentices. In 1800 the Surgeons' Company became the Royal College of Surgeons, and their examinations served as a basis for both membership in the College and official licensure. Quality control finally was established in surgery. While the internist remained preoccupied with the interpretation of external signs and symptoms, the welleducated surgeon developed an intimate knowledge of structure and function that he could use effectively in his practice. Formal medical education and specialization came late to the United States Y Regulations to restrict the practice of medicine were hardly ever enforced. Regional medical societies with no power to grant licenses or to regulate practice had little influence over the quality of medical care. After the Civil War, there was a revival of medical education throughout the country. Unfortunately, many of the schools were nothing but diploma mills where the prescribed curriculum was not taught and patients were rarely seen. Even in some of the large "teaching hospitals," students were dissuaded from patient contact. For example, in 1824, instructions to medical students visiting a new institution called the Massachusetts General Hospital directed that: "Pupils are not to remain at the hospital longer than absolutely necessary. They are not to converse with patients or nurses and not to disturb medical officers or patients. "18 With the discovery of safe general anesthesia in 1846 and with the introduction of aseptic operating techniques 30 years later, surgery entered the modem age. By the 1870s surgery had become painless and effective with a relatively low risk of infection. Rivalry between medicine and surgery resurfaced as increasing numbers of students showed interest in the drama of this rapidly growing specialty. 19 But there was insufficient clinical material for surgical education. In the 1890s, fewer than 5% of patients admitted to the larger hospitals underwent major sur-
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gery. Dozens of students often would attend the operative sessions. The educational value of these sessions was questionable. We are told: "Surgeons and assistants surround the patient and disregard the students who loll in their seats without an inkling of what is happening below. Most of the students see only the patient's feet and the surgeon's head. "20 In Great Britain and the United States, scarcity of material for anatomic dissection spawned the profession ofresurrection or grave robbing in early 1800 AD. In Scotland, a Mr. William Burke, influenced no doubt by excessive scientific zeal, wandered across the fine line of discretion. On 16 occasions he was responsible for the sudden and premature demise of fellow citizens in order that he might provide anatomic material for the medical school at 7 pounds, 6 shillings each. 16 The criminal court of Edinburgh contributed Mr. Burke for medical study when his peers learned of the source of his research material. Throughout the nineteenth century, the lucrative industry of grave robbing reached such alarming proportions in this country that enraged citizens rioted in many cities. One of the ugliest disturbances took place in the city of New Haven where a large university medical school obtained anatomic material by methods thought to be suspect. 21, 22 The public image of medical education suffered considerably during these years. 23 Growth of specialties and subspecialties As surgery developed, the number of specialists and specialties multiplied rapidly. At first, this trend was not popular with organized medicine, but by the end of the century, specialism was here to stay. 24 Specialists soon dominated medical societies, medical colleges, and hospital staffs.25 But it was difficult to know who had the additional education, knowledge, and interest to be considered a competent specialist. In 1917, the American Board of Ophthalmology was organized and set standards for specialty education. It established minimum training criteria and prepared examinations to be given to qualified candidates. Other specialties soon followed, and in 1933, the Advisory Board for Medical Specialties was formed to serve as a forum for specialty boards. The purpose of the boards was to elevate the standards of graduate medical education and to "promote the public welfare by determining the competence of candidates who appear voluntarily for examination. "26 In 1980, 50% of all doctors practicing in the United States were certified by at least one specialty board. This percentage increases each year. Subspecialization was recognized by the boards as early as 1936, and today certificates of special competence or
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Table I. Special certificates (certificates of special competence) granted by American Board of Medical Specialties *
Specialty and subspecialty Dennatology Dennatopathology Internal medicine Cardiovascular disease Endocrinology and metabolism Gastroenterology Hematology Infectious disease Medical oncology Nephrology Pulmonary disease Rheumatology Obstetrics and gynecology Maternal and fetal medicine Gynecologic oncology Reproductive endocrinology Pathology Blood banking Chemical pathology Dennatopathology Forensic pathology Hematology Medical microbiology Neuropathology Radioisotopic pathology Pediatrics Pediatric cardiology Pediatric endocrinology Pediatric hematology-oncology Pediatric nephrology Neonatal-perinatal medicine Psychiatry and neurology Child psychiatry Radiology Nuclear radiology Surgery Pediatric surgery
No. of certificates awarded 1972 to 1981
552 5261 1676 2704 1816 950 2434 1683 2139 1176 203 202 134 390 91
381 263 254 86 193
266 300
278 565 260 1096 819
470 383
'From Annual report and reference handbook. Evanston, Ill., 1982, American Board of Medical Specialties, Table 3, p. 51.
special qualification are issued in 29 fields (Table I). A multispecialized committee has been studying the value of a certificate of special qualification in hand surgery in the United States. The purpose of such a certificate would be to improve the quality of postresidency education in hand surgery and the care of patients with complex hand surgery problems. The question of subcertification continues under deliberation as its potential values and problems are studied.
Current challenges to surgical education
Medical education has profited greatly from electronic advances of the past few decades. MEDLARS can now find and print references on virtually any medical topic. Computer programs can quiz students on complex clinical problems and can gently explain solutions to them if they are baffled. Students no longer need to stare at the heads of assistants and the feet of the patients when they want to see a surgical procedure. It can now be brought to them by closed-circuit television within a 500 mm zoom shot of the scalpel's cutting edge. Books are photocopied, lectures are recorded, and the entire medical world is readily available. But despite these advances, education of the surgeon still depends on the direct contact of student, patient, and teacher. 11, 27 Compare the best computer program with bedside teaching rounds for clinical diagnosis. What videotape can instruct the surgical resident how to separate the plane between Dupuytren's fascia and skin? The surgeon's education requires many years of close professional contact with both teachers and patients. The teacher, patient, and student must meet constantly at the bedside, in the clinic, and in the operating room. In many respects, surgical education has not changed much since the days of Hippocrates or the old hospitals of Baghdad. In some ways, however, we are beginning to see enormous changes that are due not as much to electronic advances as to the challenges from the law, the public, and the government. Recently we have become more acutely aware of a moral and legal dilemma of surgical education that has been with us for some time. Thirty years ago, "ward cases" were operated upon by interns and residents. "Private cases" were operated upon by visiting surgeons. Today, however, the vast majority of Americans are entitled to private medical care because of the expansion of government and commercial insurance. As a result, the census of the municipal hospitals is shrinking, and many are closing altogether. In some communities, the "ward patient" is vanishing. 28 In surgery, where technical skills must be practiced to be learned, education is incomplete unless the resident holds the knife and repairs the tissues. The question is "Whose tissues?" If all patients soon become "private patients," and if the surgical resident is not permitted to operate on these "private patients" during his years of training, then he will never cut and repair human tissue until the day he enters practice. Picture each first of July when thousands of eager young surgeons who have never operated previously because of
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medical "ethics and morality" are simultaneously unleashed from our training programs and descend upon our nation to do their first bowel resection, tendon graft, or spine stabilization. Will the American public try to suffer their illnesses silently until the first snowfall? Is it not more sensible for the surgical resident and fellow to assume increasing operative responsibilities under appropriate supervision and surveillance as they acquire technical competence? Certainly there should be skills laboratories where student surgeons can practice techniques on animals or plastic models. Surgical anatomy should be learned from postmortem dissections. Nothing, however, can substitute for the experience gained by real surgery on real patients. As surgical educators, we should be able to observe, judge, and guide the resident or fellow without jeopardizing the health of any patient, rich or poor, insured or uninsured, private or ward. We should alert the public, government, law, and press that unless there is a change in the present attitude, the partially prepared surgeon soon may pose a national health problem. The medical profession today is suffering a loss of image. To some extent this may be due to the occasional lapse of taste or judgment by our colleagues. In part, it is due to the rise of consumerism. The patient has been taught to doubt, to question, to get a second opinion. The doctor has also lost image and stature as the result of the lucrative business of malpractice litigation where errors are occasionally exaggerated, misinterpreted, or invented by lawyer or patient. 29 We should also be aware of the subtle effect of the words that are now being used to describe our profession. 30 Government forms no longer describe us as "doctors' '; we are "providers." They are no longer "patients"; they are "consumers." "The medical profession" is the "health care industry"; "fees" are "prices." Recently, federal and local governments have begun to attack medical education in an effort to decrease costs. Although medical school tuition is increasing, there are fewer grants and loans. As a result of proposed federal legislation, any doctor associated with a hospital-based teaching service may be penalized. 3 ! He will be reimbursed less for the treatment of a federally insured patient than his nonteaching colleagues who are rendering the same service. In several states, new laws have been passed that place a ceiling on hospital expenses for inpatient services. 32 Few allowances are made for the new techniques that allow us to take better care of the patient at higher cost. We may soon find that our choice of treatment will be determined not as much
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by medical priorities as by financial considerations. To replace an amputated finger of a 55-year-old man will give him only 10 "finger-years" of work. This may not be considered cost effective, and we may be directed not to replant the finger so that our health care dollar may be better spent. How ironic that a nation that has criticized commercialism in medicine soon may ask us to consider cost ahead of quality and need. Recently, deans of great medical schools have joined others in concluding that subspecialization is separating the patient from the doctor. This would suggest that the orthopedic surgeon who chooses to specialize in hand surgery, for example, is less concerned and less understanding of her patients than if she were also to pin hips and peer into knee joints. Is this true? One suggested solution to this presumed problem of the increasing distance between doctor and patient is to take the medical student away from the liberal arts campus and teach her humanism through an "alternative pathway" in the medical school. 33 Are the medical schools really more sensitive to humanism than our universities? It is charged that more fellowships and more subspecialization in a field, such as hand surgery, fragment medicine and that this trend will deprive the surgeon of an important part of his education and practice. 34 We would agree that subcertification must never be considered as a restrictive or exclusionary right to practice. The 1000 or so men and women specializing in hand surgery cannot possibly care for all the 16 million patients with upper limb disorders. 35 We must be certain that the general, plastic, and orthopedic surgery residents are thoroughly educated in the principles and techniques of hand surgery. They must be competent to treat an acutely injured hand and to perform appropriate reconstructive surgery in the course of their practice. Should an unusual problem arise in which their experience is limited, however, they should be able to identify the qualified hand surgeon, one who has had additional education and experience in the field. Occasionally, problems may arise because of competition between fellows and residents for clinical material. 6 , 7 In most programs, however, soon after a surgical fellowship is established, there are more cases to treat, and both the quality of care and teaching opportunities are improved for all house officers.
Educational activities of the American Society for Surgery of the Hand The vigor and growth of our specialty are well reflected in the educational activities of our Society. Thirty-seven years ago, there were 35 members and
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eight scientific papers at our annual meeting. This year, we have 676 members. In our 1983 annual program, we had 56 scientific papers at the plenary sessions, 33 papers at the Residents' and Fellows' Conference, 24 instructional courses, 16 panels, and a hall full of exhibits. Just to note a few of the Society's activities that were initiated this year demonstrates our commitment to education: Regional review courses in nine cities, September IOctober 1982; Residents' and Fellows' Conference, March 6, 1983; Museum and Library of the American Society for Surgery of the Hand, cosponsored by the Bunnell Memorial Committee-the first such library in the world-opened Nov. 6, 1982; Instructional course lectures, March 8 and 9, 1983; and ASSH News, July, October, and December 1982. Our ongoing activities are too numerous to list. Our Fellowship Review Committee has just completed an evaluation of 36 postresidency fellowship programs. It will be published soon. Last year, we distributed our third hand surgery self-assessment examination. It is expected that the Greek proverb printed on the back cover of the examination booklet would win nods of approval from the exasperated examinee. Translated, it reads: "Fools can ask more questions than the wise can answer." Our department of continuing education sponsored eight courses throughout the country that covered topics as diverse as the primary care of the injured hand to the technical aspects of rigid internal fixation and small joint arthroplasty. In June 1982, we held a combined meeting with the British Society for Surgery of the Hand in Bath, England. The midyear members' meeting was held in Boston in October 1982. For all our activities, we are particularly grateful to the staff at the central office so ably administered by Ms. Gail Gorman and, of course, to our Council, committee chairman, and all our members. Conclusion Dr. Joseph Boyes36 has reminded us of a quotation of Bernard of Chartres 37 and Sir Isaac Newton: "If I have seen farther, it is by standing on the shoulders of giants. " And we owe so much to the giants of our own Society: Sterling Bunnell, Joseph Boyes, Sumner Koch, Leo Mayer, Emanual Kaplan, Guy Pulvertaft. But in education, there is another quotation that is equally appropriate. It comes not from Newton, nor Galen, nor Hippocrates. Rather I quote Oscar Hammerstein II: "If you become a teacher, by your pupils you'll be taught." Perhaps some of our best teachers are our residents and fellows. Often we may reflect on how much of our busy day has been spent on teaching rounds, conferences, lec-
tures, preparing manuscripts, and performing research. Surely life would be simpler and easier for many of us if we were to accept our government's advice and spend less time in medical education. But we need only to look around us today and to see how few of us have listened to government officials, state legislators, and television commentators. We know that education of the surgical specialist is our responsibility. 38 It is too important to be left to anyone else. It is as crucial as patient care, for those we teach today will treat their patients and will be the teachers of other doctors in the decades to come. As educators in the world's most important profession, we have a long and proud heritage. And we do not intend to abandon it. Thank you for the privilege and honor of being your President this year. I enjoyed every minute of it. REFERENCES 1. Eichna LW: A medical-school curriculum for the 1980's.
N Engl J Med 308:18-21,1983 2. The American Board of Medical Specialties: Medical specialty certification and related matters. An information booklet. Evanston, IlL, 1982, ABMS 3. 1982-83 Directory of residency training programs. Dallas, 1982, American Medical Association 4. Levit EJ, Sabshin M, Mueller CB: Trends in graduate medical education and specialty certification. A tracking study of United States medical school graduates. N Engl J Med 290:545-9, 1974 5. Gunby P: Medical education: Prosperitas interrupta. JAMA 249:12-3, 1983 6. McQueen DV, Celentano DO: Plastic surgery practice and training. Baltimore, 1982, American Association of Plastic Surgeons 19817 . Post-graduate orthopaedic fellowships "ACORE"-Advisory Council for Orthopaedic Resident Education. Chicago, 1981, American Academy of Orthopaedic Surgeons 8. Crowley AE: Graduate medical education in the United States. JAMA 248:3271-5, 1982 9. Lyons AS, Petrucelli RJ: Medicine-An illustrated history. New York, 1978, Harvey N Abrams, Inc, pp 163205,250-61 10. Kudlien F: Medical education in classical antiquity. In O'Malley CD, editor: The history of medical education. Berkeley, 1970, University of California Press, pp 3-38 II. Singer C: A short history of medicine. Introductory medical principles to students and non-medical readers. Oxford, 1928, Clarendon Press 12. Majno G: The healing hand. Man and wound in the ancient world. Cambridge, 1975, Harvard University Press, pp 179, 395 13. Hamarneh S: Medical education and practice in medieval Islam. In O'Malley CD, editor: The history of medical
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14.
15. 16. 17. 18. 19.
20.
21.
22.
23. 24. 25.
education. Berkeley, 1970, University of California Press, pp 39-72 Talbot CH: Medical education in the Middle Ages. In O'Malley CD, editor: The history of medical education. Berkeley, 1970, University of California Press, pp 73-88 Keen WW: Early history of practical anatomy. Philadelphia, 1874, JB Lippincott Co Encyclopedia Brittanica, ed 11. Chicago, 1910, Encyclopedia Brittanica, Inc, pp 920-39 Marks G, Beatty WK: The story of medicine in America. New York, 1973, Charles Scribner & Sons Numbers RL: The education of American physicians. Berkeley, 1980, University of California Press, p 194 Bowditch NI: History of the Massachusetts General Hospital, ed 2. Cambridge, 1876, John Wilson & Son, pp 215-76 Flexner A: Medical education in the United States and Canada. New York, 1910, Carnegie Foundation for the Advancement of Teaching, p 116 Blake JB: Anatomy. In Numbers PL, editor: The education of American physicians. Berkeley, 1980, University of California Press, p 37 Rothstein WG: American physicians in the nineteenth century. From sects to sciences. Baltimore, 1972, John Hopkins University Press Blake JB: The development of American anatomy acts. 1 Med Educ 30:431-9, 1958 Keith A: Menders of the maimed. London, 1919, Oxford University Press Beecher HK, Altschule MD: Medicine at Harvard. The first three hundred years. Hanover, N.H., 1977, The University Press of New England, pp 14, 31-6, 126-64
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26. Annual report and reference handbook. Evanston, Ill., 1982, American Board of Medical Specialties 27. SmithN: Training of the intern. lAMA 114: 1705-8,1940 28. Schramm CJ: The teaching hospital and the future role of state government. N Engl J Med 308:41-5, 1983 29. Longerbeam JK: The national perspective: A crisis may be in the wings. Bull Am Coil Surg 68:2-10, 1983 30. Fein R: What is wrong with the language of medicine? N Engl J Med 306:863-4, 1982 31. Federal register: Rules and regulations, vol 48, no. 42, p 8911, March 2, 1983 32. Commonwealth of Massachusetts, chapter 372, An act related to establishment of hospital rates of payments and charges. Approved Aug. 10, 1982 33. Harvard medical area focus: A new approach to medical education at Harvard Medical School. Dean's "alternative pathway." Workshop, May 13, 1982, P 1-8 34. Smith RJ: Subcertification for hand surgery. J HAND SURG 7:107-12,1982 35. Kelsey JL, Pastides H, Kreiger N, et al: Upper extremity disorders: A survey of their frequency and cost in the United States. St. Louis, 1980, The CV Mosby Co, pp 1-2,39-65 36. Boyes JH: On the shoulders of giants. Notable names in hand surgery. Philadelphia, 1976, JB Lippincott Co 37. Merton RK: On the shoulders of giants. A shandean postscript. New York, 1965, Harcourt Brace Jovanovich, p 268 38. Engel GL: The biopsychosocial model and medical education. Who are to be the teachers? N Engl J Med 306:802-5, 1982
Subscribers who wish to secure copies or volumes of the early issues of THE JOURNAL OF HAND SURGERY should contact University Microfilms, 300 N Zeeb Road, Ann Arbor, Mich., (313) 761-4700. UM not only provides microfilm or microfiche, but will photocopy complete issues or volumes at a charge of 20¢ per page.
Education of the surgical specialist Richard J. Smith, M.D., Boston, Mass.
In
June of 1982, 16,000 American men and women completed one of the world's most competitive and difficult educational experiences. They were graduated from medical school. By now, almost all of them have been licensed to begin private practice, yet few will do so since most will agree with their deans that they are not prepared to treat patients. 1 Medical school has provided only the foundations in basic science and clinical skills. The recent graduates will need to take a postgraduate residency in order to become competent clinicians. Of the 16,000 graduates, 6700 will become residents in one of the surgical specialties. 2. 3 After several more years of study and work, now older and more deeply in debt, they finally will become surgical specialists. 4 • 5 But despite the lofty and dizzying heights of chief residency, many will decide to go still further and will seek a fellowship. 6-8 If these superspecialists expect to hear enthusiastic cheers of support from those who admire their commitment to scholarship and science, they will be disappointed. Colleagues will accuse them of separating themselves from the substance of medicine-treating the "whole person. " Wives or husbands will complain of the prospect of more years of meager incomes and oppressive night-call schedules. In-laws, who long ago concluded that the marriage was a terrible mistake, will now be convinced that these aging students have no intention of ever becoming "real doctors. " Educating surgical specialists, superannuated scholars now in their tenth year of professional study, is a major responsibility. But whose responsibility is it? Presidential address to the Thirty-eighth Annual Meeting· of the American Society for Surgery of the Hand, Anaheim, Calif., March 8, 1983. Received for publication April 25, 1983; accepted in revised form April 29, 1983. Reprint requests: Richard J. Smith, M.D., Massachusetts General Hospital, ACC427, Boston, MA 02114.
Does it fall to the universities and medical schools or to the government? Are those who practice a profession best able to teach it? And who should monitor this process? Perhaps a glimpse into the past and a look at today's challenges may help us to answer some of these questions. History of surgical education
Specialization developed soon after the ongm of medicine itself. The son of Apollo, god of medicine, was the physician Aesculapius. As Aesculapius was half mortal and half god, he seems to have served as a role model for some of our surgeons today. Before he was struck down by a thunderbolt, bringing a premature end to a very promising medical career, he had a large and scholarly family. His sons Machaon and Podalirios became patron gods of surgery and medicine; his daughters Panacea and Hygeia were identified with pharmacology and public health. 9 Thus it took only three generations before specialists appeared on Mount Olympus. The prestige of this medical dynasty was not to be rivaled until the appearance of the Warrens in Boston and the Mayos in Minnesota many centuries later. From 600 to 400 BC temples of medicine were built throughout Greece.tO Each was like a health spa and religious shrine combined, where patients with obscure internal diseases consulted sacred physicians. Cure was a subject of divine jurisdiction. Such problems as fractures, dislocations, and wounds, however, were treated by the technical doctors-the "techniatrike "-the surgeons. Unlike physicians, surgeons were not sacred. Their social position was somewhat above that of manual worker but not nearly as celestial as that of the physician. 11 This social and professional separation of physician and surgeon was to set a recurring theme. The rift was partially bridged in the fourth century BC when informal associations were developed. throughout Greece where THE JOURNAL OF HAND SURGERY
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Fig. I. In the Twin Temples of Kom Ombro, this hieroglyphic, from 100 BC, shows scalpels, retractors, scissors, trephines, and other instruments used by surgeons at that time.
doctors would teach and practice medicine. The most influential school was that of Hippocrates at Cos. There, lectures were given that covered the fields of surgery, medicine, and ethics. Students were taught at the bedside of patients, and doctors bore the credit or responsibility for the outcome of their treatment. In 300 BC a medical school was built in Alexandria. There, for the first time, human dissection was permitted and demonstrated. Anatomic studies led to rapid advances in understanding disease and deformity, and Alexandria soon became the center of the medical world. Hieroglyphics still can be seen at the temple of Kom Ombro; these show the scalpels, scissors, probes, and retractors used by surgeons in 100 BC (Fig. 1). In Rome, a principal preoccupation of the emperors was war. Thus it is not surprising that the focus of medical education was the treatment of war wounds, and surgeons were preeminent in the medical hierarchy. Celsus (30 AD) described the surgeon as "a peculiar sort of physician who should have special education from childhood onward." Virtually no attention was
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paid to research. Technical competence was the goal of medical education, and there was little progress in the understanding of disease. From Egypt and Rome, the medical spotlight then turned east, and the result was to influence medical education for centuries. Galen was born in Pergamum (Asia Minor) in 130 AD. Since human dissection was no longer practiced, he was handicapped by an inaccurate appreciation of human structure and function,12 yet for 1200 years, his books were never questioned throughout Europe. What he wrote was considered fact. Anatomic and physiologic inquiries ceased completely, and Europe passed into the Dark Ages of medicine. There were no dissections; there were no hospitals; there was no medical inquiry or research. In Islam, however, things were different. 13 Libraries flourished. The first hospital was built in Baghdad in 800 AD, and specialization was encouraged. In order to maintain high levels of medical care, all physicians of Baghdad were required to take and pass an examination before being permitted to practice in their field. These were the first boards and the first medical licenses. In Europe, education of the surgeon was officially separated from that of the physician by a decree of the Lateran Council of 1215 that ruled that surgery and cautery could not be practiced by those belonging to several major ecclesiastic orders. 14 As a result, surgeons could no longer work in church-dominated universities such as those of Oxford, Cambridge, and Paris. Thereafter, surgery was taught predominantly through apprenticeship, and there was little academic control over what was taught and what was learned. In an effort to improve the quality of surgical education, the surgeons took it upon themselves to qualify students. In Great Britain, for example, they formed a Surgeons' Company and set high standards of ethics and competence for membership. Applicants were judged on their manual dexterity and on their ability to pass rigorous examinations covering all branches of medicine and surgery. But the Surgeons' Company had no legal control over those who could practice in their field. When, in 1462, King Edward IV granted a charter authorizing barbers to practice surgery, the prestige of the surgeons slipped considerably. The well-educated, skillful surgeons and the "barber-surgeons" treated similar problems. By contrast, the physicians were more carefully regulated. According to the Medical Acts of 1511 and 1522 in England, only those who passed examinations regulated by the College of Physicians could practice medicine. Thereafter, surgeons in Britain were addressed as "mister" even if they had a university degree.
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The separation of surgeons from barbers paralleled advances in the study of human anatomy. 15 In 1543, Vesailius published the anatomic text, De Humani Corporis Fabrica. Many of his findings and illustrations disagreed with the suppositions of Galen and Avicenna. The public anatomic demonstrations by Vesailius were extremely popular and well attended. Anatomy, and with it surgery, became the first scientifically oriented medical discipline of the Renaissance. 16 In 1745, William Cheselden established a Surgeons' Hall for Anatomic Dissection in London. Barbers were excluded. Soon other anatomy amphitheaters were built as adjuncts to voluntary hospitals where students served several years as surgical apprentices. In 1800 the Surgeons' Company became the Royal College of Surgeons, and their examinations served as a basis for both membership in the College and official licensure. Quality control finally was established in surgery. While the internist remained preoccupied with the interpretation of external signs and symptoms, the welleducated surgeon developed an intimate knowledge of structure and function that he could use effectively in his practice. Formal medical education and specialization came late to the United States Y Regulations to restrict the practice of medicine were hardly ever enforced. Regional medical societies with no power to grant licenses or to regulate practice had little influence over the quality of medical care. After the Civil War, there was a revival of medical education throughout the country. Unfortunately, many of the schools were nothing but diploma mills where the prescribed curriculum was not taught and patients were rarely seen. Even in some of the large "teaching hospitals," students were dissuaded from patient contact. For example, in 1824, instructions to medical students visiting a new institution called the Massachusetts General Hospital directed that: "Pupils are not to remain at the hospital longer than absolutely necessary. They are not to converse with patients or nurses and not to disturb medical officers or patients. "18 With the discovery of safe general anesthesia in 1846 and with the introduction of aseptic operating techniques 30 years later, surgery entered the modem age. By the 1870s surgery had become painless and effective with a relatively low risk of infection. Rivalry between medicine and surgery resurfaced as increasing numbers of students showed interest in the drama of this rapidly growing specialty. 19 But there was insufficient clinical material for surgical education. In the 1890s, fewer than 5% of patients admitted to the larger hospitals underwent major sur-
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gery. Dozens of students often would attend the operative sessions. The educational value of these sessions was questionable. We are told: "Surgeons and assistants surround the patient and disregard the students who loll in their seats without an inkling of what is happening below. Most of the students see only the patient's feet and the surgeon's head. "20 In Great Britain and the United States, scarcity of material for anatomic dissection spawned the profession ofresurrection or grave robbing in early 1800 AD. In Scotland, a Mr. William Burke, influenced no doubt by excessive scientific zeal, wandered across the fine line of discretion. On 16 occasions he was responsible for the sudden and premature demise of fellow citizens in order that he might provide anatomic material for the medical school at 7 pounds, 6 shillings each. 16 The criminal court of Edinburgh contributed Mr. Burke for medical study when his peers learned of the source of his research material. Throughout the nineteenth century, the lucrative industry of grave robbing reached such alarming proportions in this country that enraged citizens rioted in many cities. One of the ugliest disturbances took place in the city of New Haven where a large university medical school obtained anatomic material by methods thought to be suspect. 21, 22 The public image of medical education suffered considerably during these years. 23 Growth of specialties and subspecialties As surgery developed, the number of specialists and specialties multiplied rapidly. At first, this trend was not popular with organized medicine, but by the end of the century, specialism was here to stay. 24 Specialists soon dominated medical societies, medical colleges, and hospital staffs.25 But it was difficult to know who had the additional education, knowledge, and interest to be considered a competent specialist. In 1917, the American Board of Ophthalmology was organized and set standards for specialty education. It established minimum training criteria and prepared examinations to be given to qualified candidates. Other specialties soon followed, and in 1933, the Advisory Board for Medical Specialties was formed to serve as a forum for specialty boards. The purpose of the boards was to elevate the standards of graduate medical education and to "promote the public welfare by determining the competence of candidates who appear voluntarily for examination. "26 In 1980, 50% of all doctors practicing in the United States were certified by at least one specialty board. This percentage increases each year. Subspecialization was recognized by the boards as early as 1936, and today certificates of special competence or
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Table I. Special certificates (certificates of special competence) granted by American Board of Medical Specialties *
Specialty and subspecialty Dennatology Dennatopathology Internal medicine Cardiovascular disease Endocrinology and metabolism Gastroenterology Hematology Infectious disease Medical oncology Nephrology Pulmonary disease Rheumatology Obstetrics and gynecology Maternal and fetal medicine Gynecologic oncology Reproductive endocrinology Pathology Blood banking Chemical pathology Dennatopathology Forensic pathology Hematology Medical microbiology Neuropathology Radioisotopic pathology Pediatrics Pediatric cardiology Pediatric endocrinology Pediatric hematology-oncology Pediatric nephrology Neonatal-perinatal medicine Psychiatry and neurology Child psychiatry Radiology Nuclear radiology Surgery Pediatric surgery
No. of certificates awarded 1972 to 1981
552 5261 1676 2704 1816 950 2434 1683 2139 1176 203 202 134 390 91
381 263 254 86 193
266 300
278 565 260 1096 819
470 383
'From Annual report and reference handbook. Evanston, Ill., 1982, American Board of Medical Specialties, Table 3, p. 51.
special qualification are issued in 29 fields (Table I). A multispecialized committee has been studying the value of a certificate of special qualification in hand surgery in the United States. The purpose of such a certificate would be to improve the quality of postresidency education in hand surgery and the care of patients with complex hand surgery problems. The question of subcertification continues under deliberation as its potential values and problems are studied.
Current challenges to surgical education
Medical education has profited greatly from electronic advances of the past few decades. MEDLARS can now find and print references on virtually any medical topic. Computer programs can quiz students on complex clinical problems and can gently explain solutions to them if they are baffled. Students no longer need to stare at the heads of assistants and the feet of the patients when they want to see a surgical procedure. It can now be brought to them by closed-circuit television within a 500 mm zoom shot of the scalpel's cutting edge. Books are photocopied, lectures are recorded, and the entire medical world is readily available. But despite these advances, education of the surgeon still depends on the direct contact of student, patient, and teacher. 11, 27 Compare the best computer program with bedside teaching rounds for clinical diagnosis. What videotape can instruct the surgical resident how to separate the plane between Dupuytren's fascia and skin? The surgeon's education requires many years of close professional contact with both teachers and patients. The teacher, patient, and student must meet constantly at the bedside, in the clinic, and in the operating room. In many respects, surgical education has not changed much since the days of Hippocrates or the old hospitals of Baghdad. In some ways, however, we are beginning to see enormous changes that are due not as much to electronic advances as to the challenges from the law, the public, and the government. Recently we have become more acutely aware of a moral and legal dilemma of surgical education that has been with us for some time. Thirty years ago, "ward cases" were operated upon by interns and residents. "Private cases" were operated upon by visiting surgeons. Today, however, the vast majority of Americans are entitled to private medical care because of the expansion of government and commercial insurance. As a result, the census of the municipal hospitals is shrinking, and many are closing altogether. In some communities, the "ward patient" is vanishing. 28 In surgery, where technical skills must be practiced to be learned, education is incomplete unless the resident holds the knife and repairs the tissues. The question is "Whose tissues?" If all patients soon become "private patients," and if the surgical resident is not permitted to operate on these "private patients" during his years of training, then he will never cut and repair human tissue until the day he enters practice. Picture each first of July when thousands of eager young surgeons who have never operated previously because of
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medical "ethics and morality" are simultaneously unleashed from our training programs and descend upon our nation to do their first bowel resection, tendon graft, or spine stabilization. Will the American public try to suffer their illnesses silently until the first snowfall? Is it not more sensible for the surgical resident and fellow to assume increasing operative responsibilities under appropriate supervision and surveillance as they acquire technical competence? Certainly there should be skills laboratories where student surgeons can practice techniques on animals or plastic models. Surgical anatomy should be learned from postmortem dissections. Nothing, however, can substitute for the experience gained by real surgery on real patients. As surgical educators, we should be able to observe, judge, and guide the resident or fellow without jeopardizing the health of any patient, rich or poor, insured or uninsured, private or ward. We should alert the public, government, law, and press that unless there is a change in the present attitude, the partially prepared surgeon soon may pose a national health problem. The medical profession today is suffering a loss of image. To some extent this may be due to the occasional lapse of taste or judgment by our colleagues. In part, it is due to the rise of consumerism. The patient has been taught to doubt, to question, to get a second opinion. The doctor has also lost image and stature as the result of the lucrative business of malpractice litigation where errors are occasionally exaggerated, misinterpreted, or invented by lawyer or patient. 29 We should also be aware of the subtle effect of the words that are now being used to describe our profession. 30 Government forms no longer describe us as "doctors' '; we are "providers." They are no longer "patients"; they are "consumers." "The medical profession" is the "health care industry"; "fees" are "prices." Recently, federal and local governments have begun to attack medical education in an effort to decrease costs. Although medical school tuition is increasing, there are fewer grants and loans. As a result of proposed federal legislation, any doctor associated with a hospital-based teaching service may be penalized. 3 ! He will be reimbursed less for the treatment of a federally insured patient than his nonteaching colleagues who are rendering the same service. In several states, new laws have been passed that place a ceiling on hospital expenses for inpatient services. 32 Few allowances are made for the new techniques that allow us to take better care of the patient at higher cost. We may soon find that our choice of treatment will be determined not as much
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by medical priorities as by financial considerations. To replace an amputated finger of a 55-year-old man will give him only 10 "finger-years" of work. This may not be considered cost effective, and we may be directed not to replant the finger so that our health care dollar may be better spent. How ironic that a nation that has criticized commercialism in medicine soon may ask us to consider cost ahead of quality and need. Recently, deans of great medical schools have joined others in concluding that subspecialization is separating the patient from the doctor. This would suggest that the orthopedic surgeon who chooses to specialize in hand surgery, for example, is less concerned and less understanding of her patients than if she were also to pin hips and peer into knee joints. Is this true? One suggested solution to this presumed problem of the increasing distance between doctor and patient is to take the medical student away from the liberal arts campus and teach her humanism through an "alternative pathway" in the medical school. 33 Are the medical schools really more sensitive to humanism than our universities? It is charged that more fellowships and more subspecialization in a field, such as hand surgery, fragment medicine and that this trend will deprive the surgeon of an important part of his education and practice. 34 We would agree that subcertification must never be considered as a restrictive or exclusionary right to practice. The 1000 or so men and women specializing in hand surgery cannot possibly care for all the 16 million patients with upper limb disorders. 35 We must be certain that the general, plastic, and orthopedic surgery residents are thoroughly educated in the principles and techniques of hand surgery. They must be competent to treat an acutely injured hand and to perform appropriate reconstructive surgery in the course of their practice. Should an unusual problem arise in which their experience is limited, however, they should be able to identify the qualified hand surgeon, one who has had additional education and experience in the field. Occasionally, problems may arise because of competition between fellows and residents for clinical material. 6 , 7 In most programs, however, soon after a surgical fellowship is established, there are more cases to treat, and both the quality of care and teaching opportunities are improved for all house officers.
Educational activities of the American Society for Surgery of the Hand The vigor and growth of our specialty are well reflected in the educational activities of our Society. Thirty-seven years ago, there were 35 members and
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eight scientific papers at our annual meeting. This year, we have 676 members. In our 1983 annual program, we had 56 scientific papers at the plenary sessions, 33 papers at the Residents' and Fellows' Conference, 24 instructional courses, 16 panels, and a hall full of exhibits. Just to note a few of the Society's activities that were initiated this year demonstrates our commitment to education: Regional review courses in nine cities, September IOctober 1982; Residents' and Fellows' Conference, March 6, 1983; Museum and Library of the American Society for Surgery of the Hand, cosponsored by the Bunnell Memorial Committee-the first such library in the world-opened Nov. 6, 1982; Instructional course lectures, March 8 and 9, 1983; and ASSH News, July, October, and December 1982. Our ongoing activities are too numerous to list. Our Fellowship Review Committee has just completed an evaluation of 36 postresidency fellowship programs. It will be published soon. Last year, we distributed our third hand surgery self-assessment examination. It is expected that the Greek proverb printed on the back cover of the examination booklet would win nods of approval from the exasperated examinee. Translated, it reads: "Fools can ask more questions than the wise can answer." Our department of continuing education sponsored eight courses throughout the country that covered topics as diverse as the primary care of the injured hand to the technical aspects of rigid internal fixation and small joint arthroplasty. In June 1982, we held a combined meeting with the British Society for Surgery of the Hand in Bath, England. The midyear members' meeting was held in Boston in October 1982. For all our activities, we are particularly grateful to the staff at the central office so ably administered by Ms. Gail Gorman and, of course, to our Council, committee chairman, and all our members. Conclusion Dr. Joseph Boyes36 has reminded us of a quotation of Bernard of Chartres 37 and Sir Isaac Newton: "If I have seen farther, it is by standing on the shoulders of giants. " And we owe so much to the giants of our own Society: Sterling Bunnell, Joseph Boyes, Sumner Koch, Leo Mayer, Emanual Kaplan, Guy Pulvertaft. But in education, there is another quotation that is equally appropriate. It comes not from Newton, nor Galen, nor Hippocrates. Rather I quote Oscar Hammerstein II: "If you become a teacher, by your pupils you'll be taught." Perhaps some of our best teachers are our residents and fellows. Often we may reflect on how much of our busy day has been spent on teaching rounds, conferences, lec-
tures, preparing manuscripts, and performing research. Surely life would be simpler and easier for many of us if we were to accept our government's advice and spend less time in medical education. But we need only to look around us today and to see how few of us have listened to government officials, state legislators, and television commentators. We know that education of the surgical specialist is our responsibility. 38 It is too important to be left to anyone else. It is as crucial as patient care, for those we teach today will treat their patients and will be the teachers of other doctors in the decades to come. As educators in the world's most important profession, we have a long and proud heritage. And we do not intend to abandon it. Thank you for the privilege and honor of being your President this year. I enjoyed every minute of it. REFERENCES 1. Eichna LW: A medical-school curriculum for the 1980's.
N Engl J Med 308:18-21,1983 2. The American Board of Medical Specialties: Medical specialty certification and related matters. An information booklet. Evanston, IlL, 1982, ABMS 3. 1982-83 Directory of residency training programs. Dallas, 1982, American Medical Association 4. Levit EJ, Sabshin M, Mueller CB: Trends in graduate medical education and specialty certification. A tracking study of United States medical school graduates. N Engl J Med 290:545-9, 1974 5. Gunby P: Medical education: Prosperitas interrupta. JAMA 249:12-3, 1983 6. McQueen DV, Celentano DO: Plastic surgery practice and training. Baltimore, 1982, American Association of Plastic Surgeons 19817 . Post-graduate orthopaedic fellowships "ACORE"-Advisory Council for Orthopaedic Resident Education. Chicago, 1981, American Academy of Orthopaedic Surgeons 8. Crowley AE: Graduate medical education in the United States. JAMA 248:3271-5, 1982 9. Lyons AS, Petrucelli RJ: Medicine-An illustrated history. New York, 1978, Harvey N Abrams, Inc, pp 163205,250-61 10. Kudlien F: Medical education in classical antiquity. In O'Malley CD, editor: The history of medical education. Berkeley, 1970, University of California Press, pp 3-38 II. Singer C: A short history of medicine. Introductory medical principles to students and non-medical readers. Oxford, 1928, Clarendon Press 12. Majno G: The healing hand. Man and wound in the ancient world. Cambridge, 1975, Harvard University Press, pp 179, 395 13. Hamarneh S: Medical education and practice in medieval Islam. In O'Malley CD, editor: The history of medical
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education. Berkeley, 1970, University of California Press, pp 39-72 Talbot CH: Medical education in the Middle Ages. In O'Malley CD, editor: The history of medical education. Berkeley, 1970, University of California Press, pp 73-88 Keen WW: Early history of practical anatomy. Philadelphia, 1874, JB Lippincott Co Encyclopedia Brittanica, ed 11. Chicago, 1910, Encyclopedia Brittanica, Inc, pp 920-39 Marks G, Beatty WK: The story of medicine in America. New York, 1973, Charles Scribner & Sons Numbers RL: The education of American physicians. Berkeley, 1980, University of California Press, p 194 Bowditch NI: History of the Massachusetts General Hospital, ed 2. Cambridge, 1876, John Wilson & Son, pp 215-76 Flexner A: Medical education in the United States and Canada. New York, 1910, Carnegie Foundation for the Advancement of Teaching, p 116 Blake JB: Anatomy. In Numbers PL, editor: The education of American physicians. Berkeley, 1980, University of California Press, p 37 Rothstein WG: American physicians in the nineteenth century. From sects to sciences. Baltimore, 1972, John Hopkins University Press Blake JB: The development of American anatomy acts. 1 Med Educ 30:431-9, 1958 Keith A: Menders of the maimed. London, 1919, Oxford University Press Beecher HK, Altschule MD: Medicine at Harvard. The first three hundred years. Hanover, N.H., 1977, The University Press of New England, pp 14, 31-6, 126-64
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26. Annual report and reference handbook. Evanston, Ill., 1982, American Board of Medical Specialties 27. SmithN: Training of the intern. lAMA 114: 1705-8,1940 28. Schramm CJ: The teaching hospital and the future role of state government. N Engl J Med 308:41-5, 1983 29. Longerbeam JK: The national perspective: A crisis may be in the wings. Bull Am Coil Surg 68:2-10, 1983 30. Fein R: What is wrong with the language of medicine? N Engl J Med 306:863-4, 1982 31. Federal register: Rules and regulations, vol 48, no. 42, p 8911, March 2, 1983 32. Commonwealth of Massachusetts, chapter 372, An act related to establishment of hospital rates of payments and charges. Approved Aug. 10, 1982 33. Harvard medical area focus: A new approach to medical education at Harvard Medical School. Dean's "alternative pathway." Workshop, May 13, 1982, P 1-8 34. Smith RJ: Subcertification for hand surgery. J HAND SURG 7:107-12,1982 35. Kelsey JL, Pastides H, Kreiger N, et al: Upper extremity disorders: A survey of their frequency and cost in the United States. St. Louis, 1980, The CV Mosby Co, pp 1-2,39-65 36. Boyes JH: On the shoulders of giants. Notable names in hand surgery. Philadelphia, 1976, JB Lippincott Co 37. Merton RK: On the shoulders of giants. A shandean postscript. New York, 1965, Harcourt Brace Jovanovich, p 268 38. Engel GL: The biopsychosocial model and medical education. Who are to be the teachers? N Engl J Med 306:802-5, 1982
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