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Edward D. Churchill and the “rectangular” surgical residency
Volume 136 Number 5
SURGERY NOVEMBER 2004
Historical paper Edward D. Churchill and the ‘‘rectangular’’ surgical residency Hermes C. Grillo, MD, Boston, Mass
From the Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
SURGICAL TRAINING IN THE UNITED STATES was limited, ungraded, and of apprentice character until the introduction by William Halsted in 1889 of a transformational progressive and science-based but steeply pyramidal program, adapted from the German model. A single individual might emerge as a fully trained, potential professor of surgery after prolonged and intensive apprenticeship. In a second transformational point, after establishment of national standards for complete surgical training by the new American Board of Surgery (ABS) in 1937, Edward Delos Churchill formulated a ‘‘rectangular’’ program of residency to provide complete training to a smaller number of candidates, emphasizing peer group education in a school of surgery, not dominated by a single individual. THE HALSTED RESIDENCY AND ITS INFLUENCE The surgical training program instituted at Johns Hopkins by Halsted in 1889 was new to the United States. Halsted had been greatly impressed during his European studies by the proficiency,
Accepted for publication September 13, 2004. Reprint requests: Hermes C. Grillo, MD, Massachusetts General Hospital, Blake 1570, 55 Fruit Street, Boston, MA 02114. Surgery 2004;136:947-52. 0039-6060/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.surg.2004.09.002
depth of understanding, and wealth of experience of German surgeons. The system of training that he designed at Hopkins was closely modeled on the German plan.1 William Osler, also influenced by German scientific medicine, said that Halsted had come back from Germany very much ‘‘verdeutsched, and held that there were only three or four good surgeons in the world and all of them were German.’’2 Halsted’s belief was that ‘‘the hospital, the operating room and the wards should be laboratories, laboratories of the highest order, and we know from experience that where this conception prevails, not only is the cause of higher education and of medical science best served, but also the welfare of the patient is best promoted.’’ He stated that to accomplish these goals, ‘‘We need a system, and we will surely have it, which will produce not only surgeons but surgeons of the highest type, men who will stimulate the first youths of our country to study surgery and to devote their energies and their lives to raising the standard of surgical science.’’1 Eight interns were selected yearly by Halsted. Four stayed only one year and four remained for various terms. One became house surgeon, with the other three more or less in line for preferment. Staff vacancies occurred for these men only rarely. Their advancement was not guaranteed. Halsted proudly remarked that his applicants would gladly serve ten years for this opportunity. He believed that their zeal only increased with the passing of the years. He intended to adopt ‘‘as closely as SURGERY 947
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feasible the German plan.’’ He hoped that these top graduates would become professors of surgery at leading medical schools. Will Sealy, trained in the Hopkins tradition at Duke, concluded as follows: ‘‘What are the characteristics of the GermanHalsted-Hopkins system? It is a strict pyramid with an autocratic chief. . The period of training is long and indefinite.’’3 The example of the Halsted residency and the superior surgeon it produced led many centers to follow suit.4 Among these were Yale, the Peter Bent Brigham in Boston, and Duke. The professors of surgery in each of these institutions were Halstedtrained. The steeply pyramidal system of surgical residency did not then appear disadvantageous because men who had only two or three years of such training could return to their communities already more knowledgeable than most in the art and science of surgery. The example of Johns Hopkins, however, did not immediately effect universal change in surgical education in the United States. At the University of Pennsylvania, for example, a two-year rotating internship was required by law. ‘‘Up until 1922, a person desiring to go into surgery more or less apprenticed himself to a staff surgeon as his assistant and gradually built up a practice of his own on whatever crumbs fell from the table,’’ wrote Dr. Jonathan E. Rhoads.5 In 1925, Professor Charles H. Frazier created a system of three-year surgical fellowships at that hospital. In addition to clinical duties, the fellows were granted time to do research, and indeed, this was expected of them.6 At Massachusetts General Hospital (MGH), surgical training had increased to three years by 1935, but the young surgeon was still not prepared for independent practice, unlike the single resident who did reach the apex of the Hopkins pyramid. Further evolution of surgical training awaited the imposition of external national standards. Ultimately, as Churchill wrote, ‘‘The traditional manner by which the practical art was passed down from dominant master to docile apprentice underwent conversion to an interchange of knowledge between teacher and pupil.’’7 NATIONAL STANDARDS FOR SURGICAL EDUCATION The American Medical Association, spurred by the efforts of Arthur Dean Bevan of Rush, supported improvements in medical education proposed in the Flexner report in 19078 but resisted setting specialty standards in deference to its constituency of practitioners, who wished to continue to perform surgery without restriction.
Surgery November 2004
The elite American Surgical Association (ASA) at first showed little interest in working to raise the standards of American surgery beyond academic institutions. It was left to the American College of Surgeons (ACS), which had been formed under Franklin Martin in 1910, to strive effectively to elevate surgical standards in the United States, chiefly by the mechanism of demanding higher hospital standards.9 A survey of hospitals in 1919 found that only 89 of 671 met the college’s minimal criteria. Individual membership standards initially set by the college were also quite low, but this recognized that no higher standards would have been acceptable at that time. Requirements for fellowship in the ACS were indeed modest: (1) a year’s internship, usually rotating; (2) two years as an assistant under a preceptor; (3) visits to surgical clinics; and (4) submission of a list of fifty consecutive operations. After 1920, graduation from an approved medical school was added! The intriguing story of recognition of need for stricter standards for all surgeons has been told in detail.10,11 J.M.T. Finney, as president of the ASA, but who had also served as first president of the ACS, called for united effort by all surgical organizations to improve training and certification of surgeons.12 The call went unheeded. Evarts Graham, professor of surgery at Washington University, was gravely concerned about the state of surgical practice. He was critical of the lax standards of the ACS but was drawn into that organization against his will. He endeavored to bring younger surgical leaders into positions of influence in the ACS but was frustrated.10,11,13 When George Heuer, Elliot Cutler, and Allen Whipple, who had been appointed by the regents of the ACS as a committee to study surgical education, were denied the floor at the ACS for their report, they sought a forum at the ASA. Cutler, speaking of the often poorly trained practitioner of surgery, declared in indignation, ‘‘We permit this untrained individual to practice his art upon, let us be frank, the unsuspecting public.’’14 At that meeting, President Edward Archibald appealed for a system of instruction and examination for surgical qualification.15 Graham chaired the committee that resulted from this call for action. This led directly to the formation of an independent qualifying board in 1937. The board’s training requirements for examination evolved gradually. The board declared that ‘‘technical training under supervision in an institution must replace unsupervised experience obtained in private practice at the expense of an unsuspecting public.’’ A decade later the board made a senior year of institutional training
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mandatory, and preceptorships were effectively ended. Major changes in surgical training were necessary. THE CHURCHILL PLAN FOR RESIDENCY Edward D. Churchill (Fig 1) became chief of the West Surgical Service at MGH in 1931.16 He was appreciative of the skills and contributions of older surgeons but was critical of the master-apprentice mode of surgical training still current. He was troubled by the ‘‘anti-intellectual, anti-scientific’’ bias of senior surgeons, noting that ‘‘attitudes change slowly when a practical art is being passed along from master to neophyte.. [T]heir minds had crystallized.’’17 He believed that ‘‘the Halsted residency at the Hopkins . was a modified masterapprentice relationship. It was more subtle; more independence was granted to the apprentice.. nevertheless, the Halsted resident looked up to one man and one man alone.’’17 Churchill later explained, ‘‘At the MGH, I have tried to perpetuate the school concept of a group of masters, in which no single personality dominates the methods and the technology of the institution.’’17 He further wished to obviate the subservient status of the trainee under a quasi-parental, self-aggrandizing, and authoritarian tutelage, which could be so much a part of apprenticeship. ‘‘We don’t want a man to be trained under a single master, for therein lies a danger.’’18 In retrospective appraisal, he later stated: ‘‘The conversion of the intellectually sterile master-apprentice situation into a mutually stimulating teacher-pupil relationship has been one of the goals of my professional life.’’17 He noted that although the master may not relish seeing his apprentice mature, the teacher finds pleasure in watching his pupil grow. He deplored the prolonged period of servitude as assistants to older surgeons as ‘‘wastage of their vigorous and creative years of youth.’’ Churchill’s vision of a pattern for such a surgical school found expression in what was called ‘‘the Churchill Plan.’’18,19 He quoted president of Harvard A. Lawrence Lowell’s praise of the benefit of a pattern in ‘‘distinguishing the essential elements . from the accessories’’ in a plan. ‘‘Such a pattern,’’ Lowell wrote, ‘‘is by no means rigid; the final objective is perfectly definite, but the details are fluid and must be kept so throughout.. [I]f the pattern is sound, it should not be injured by changes in detail.’’ Churchill recognized a weighty institutional obligation to trainees. ‘‘The willingness of this group to deliver themselves up to an institution for four to six years of the most vital period of their life
Fig 1. Edward Delos Churchill (1895-1972), John Homans Professor of Surgery at Harvard and chief of the surgical services (1931-1962) at Massachusetts General Hospital. Photograph dates from about the time of the 1939 report (author’s collection).
without any commitment for the ultimate future places a grave responsibility on the hospital to give them the best it has.’’18 He emphasized the need to distinguish ‘‘between what is essential and what might be useful, but is not essential.’’ Needless prolongation of training was to be avoided. He saw little value for future specialists in a preliminary rotating internship. In 1940, only 3% of US hospitals offered ‘‘straight’’ internships. Churchill felt that careful diagnostic thinking and attention to preoperative and postoperative care would suffice to provide the needed medical background for a surgical trainee. PRINCIPLES OF TRAINING Dr Churchill underlined principles that should govern the curriculum.18 1. Exploitation of the intern by ‘‘repetitious performance of routine procedures’’ was to be avoided. He cited Whitehead’s caution that ‘‘prolonged routine work dulls the imagination’’
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3.
4.
5.
Fig 2. Diagram of the then current residency program (‘‘present’’) contrasted with the proposed new program, reproduced from the original report authored by Dr. Churchill and submitted to the trustees of the Massachusetts General Hospital in 1938.18 The then conventional 2-year program accepted 8 candidates, indicated by the vertical bars, only 2 of whom were allowed a further 2 years of training. Time scale in years at the left. This was a sharply fashioned ‘‘pyramid.’’ The new ‘‘rectangular’’ program (‘‘proposed’’) selected 6 candidates but offered all of them a complete surgical training (initially 4.5 years, quickly modified to 5 years). Two were offered a further supervisory year of education, which might provide preparation for an academic post. Gaps in the proposed program indicate possible elective periods.
and the more general wisdom that ‘‘necessary technical excellence can only be acquired by training which is apt to damage those energies of mind which should direct the technical skill.’’ 2. He agreed with the ABS and Halsted’s insistence on the need for exposure to basic science, distinguishing this carefully, however, from research on an original problem. This recognized that surgery was now based on laboratory sciences such as bacteriology and physiology, in addition to an earlier basis in anatomy and pathology. Churchill soon felt that basic sciences applicable to surgery were best learned in the course of surgical training itself rather than in discrete periods of instruction. He recognized that only a few men were likely to desire a prolonged period of original research. He declared, ‘‘Others desiring to attain excellence as practitioners of surgery will not be required
6.
to do penance in experimental laboratories in order to secure advanced clinical training.’’ Flexibility and tailoring to individuals was to be sought. Said Churchill, ‘‘A frozen five-year curriculum. is unthinkable as it allows no latitude for the development of individual interests and proficiencies.’’20 Staff appointments were to be ‘‘held by mature and well-qualified surgeons, willing to devote time and effort to the training of residents.’’ Responsibility of the trainee must be increased ‘‘as the individual proves himself competent to take it on his shoulders.’’ In this Churchill confirmed the principle of graded responsibility espoused by Halsted and the ABS. Lack of progressive responsibility was a defect in the apprentice system. Previously, young surgeons had completed their technical training as junior members of the staff. Lengthening the training program must lead to increased responsibility—‘‘a fundamental necessity in their education’’—and must be graded experience. An advisory board for graduate education was necessary to avoid ‘‘cumulative warping of the structure of the educational program’’ by ‘‘a series of minor changes, each judged in terms of what is immediately expedient for the care of the sick or the convenience of the administrative or professional staff.’’
The proposed program would take fewer candidates each year but keep them longer (Fig 2). The previous steep ‘‘pyramid,’’ in which only two trainees would receive four years of training, even then not calculated to prepare them for independent surgical practice, would be exchanged for five years of training for all accepted candidates. The training was calculated to provide complete surgical preparation to enable each graduate to begin surgical practice. Two would receive an extra supervisory year. These two might aim to be professors, but not necessarily. Continuation in the program was conditional, of course, on good performance and a desire to complete it. Specialty rotations were intended to teach diagnostic principles and specialty techniques rather than to impart surgical proficiency in the specialty. Emphasis on operative techniques in general surgery would begin in the second year. It was hoped that the first three years might also serve as a preparation for surgical specialties. The five-year program would provide complete training for ABS certification. The resident surgeon (later chief resident and now staff surgeon) was intended to serve as the ‘‘executive head’’ of the service, under the visiting staff, with additional obligations for
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undergraduate teaching. Churchill noted the eventual need for special funds for residents wishing to take a year or more (never less) for original investigation. The heart of the plan, of course, was substitution of a ‘‘rectangular’’ plan of resident development for the previously dominant pyramid. The pyramid might have seemed to be the best structure for a hospital selfishly, by eliminating lessfavored trainees year by year. They were sacrificed in order to polish one or two individuals, who obtained intensive operative experience in a final year or two. This served very well to produce potential professors.21 It also sent a large group of inadequately trained surgeons into practice and incidentally increased the ‘‘gross tonnage of output of laboratories’’—not necessarily of high quality. In Churchill’s words, ‘‘Half a surgical training is about as useful as half a billiard ball.’’ The rectangular plan was based on confidence that by and large candidates could be selected in their fourth year of medical school with sufficient accuracy so that they could complete a five-year training program with credit. The distraction of fierce competition for survival from year to year would be removed, allowing the residents to concentrate on their education in cooperative fashion. Churchill believed that both future professors and practitioners required similar surgical education in depth. The academically minded might add a period of scientific research, but both groups would be equally sound clinicians. Churchill often stated that he was as proud of his graduates who were practicing surgeons in a community as he was of those who became professors—and there were many in both categories. Implementation of the proposed reorganization was largely deferred by the onset of World War II. The entering class of 1946 was the first to move through the new system completely in accordance with the plan. Upper echelons of the residency staff were filled by returning veterans, but the essence of the program had changed. CONSEQUENCES OF THE PROGRAM With relatively minor adjustments, the Churchill plan proved to be highly successful. (1) It succeeded in giving complete training to superior surgeons, (2) it eliminated the human wastefulness of the pyramidal system, and (3) it responded to the nation’s surgical needs after World War II. In a time of change, this approach to residency training achieved wide recognition and was influential in redesign of surgical residency programs nationally.22 The pyramidal system was soon
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abandoned. The Halsted system had indeed revolutionized American surgical education fifty years previously, but surgical and societal needs were now better met by the rectangular model, directed by changes in educational philosophy and attitude. Dr. Churchill always expressed concern about the fragmentation of surgery by specialization. He defined specialism as of two types: (1) the acquisition of skill in applying already standardized techniques, and (2) concentration in a field in which new techniques and principles may arise, which are transferable to or from other fields. He wished to encourage concentration. ‘‘A concentrator seeks to maintain an active curiosity and interest concerning all techniques that might be useful in his area of concentration, and views his work in proper perspective with science as a whole.’’23 He regarded narrow specialism as self-limiting, ‘‘myopic,’’ and dulling to the intellect. His well-known resistance to subdivision of general surgery stemmed from these convictions. Nonetheless, Churchill showed the flexibility he espoused. Thus, he readily accepted specific changes in resident specialty assignments in the 1960s, which were justified by increasing volumes and complexity of cases. Edward Churchill approved of the fundamental changes his program had wrought. ‘‘The greatest change in this program came between . 1940 and 1960.. If I were to sum it up in one sentence, I would say the transition [was] from the classical and ancient master-apprentice training to a more contemporary age–peer group educational effort.’’ Churchill wrote, ‘‘Our whole program in graduate education. is to keep the framework flexible and adapt it to the needs and interests of the individual. If technical training dominates these years of a young surgeon’s life, he will emerge as a pure technician. It is very essential that he be taught to understand the nature of the tools that he is using, and develop a critical judgment in regard to new procedures and new tools, not merely attain proficiency in existing techniques.’’24 The ‘‘pattern’’ of the Churchill residency has stood the test of time extraordinarily well. It has served as a model, consciously or unconsciously, for modification of surgical education throughout the United States. As we consider altering our present surgical programs to meet perceived social needs and technological change, we shall do well to remember the fundamental educational principles of Halsted and Churchill and the historical evolution that brought us to this point. A fundamental principle that must remain is commitment to the educational needs of our students, who shall also be
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our successors, and concurrently to the best interests of the patients for whom we both care.
REFERENCES 1. Halsted WS. The training of the surgeon. Johns Hopkins Hosp Bull 1904;15:267-75. 2. Bordley J III, Harvey AM. Two centuries of American medicine 1776-1996. Philadelphia: WB Saunders; 1976. 3. Sealy WC. Residents and residencies. Ann Thorac Surg 1971;12:561-73. 4. Cameron JL. William Stewart Halsted: our surgical heritage. Ann Surg 1997;225:445-58. 5. Rhoads JE. Personal communication, May 22, 1998. 6. Corner CW. Two centuries of medicine: a history of the School of Medicine, University of Pennsylvania. Philadelphia: Lippincott; 1965. p. 278-9. 7. Churchill ED. Origins of American surgery. JAMA 1960;172: 219-22. 8. Flexner A. Medical education in the United States and Canada. Bulletin 4. Carnegie Foundation for the Advancement of Teaching. Boston: Merrymount Press; 1910. 9. Davis L. Fellowship of surgeons: American College of Surgeons. Chicago: Charles C. Thomas; 1960. 10. Olch PD. Evarts Graham, the American College of Surgeons and the American Board of Surgery. J Hist Med 1972;27: 247-61. 11. Grillo HC. To impart this art: The development of graduate surgical education in the United States. Surgery 1999;125: 1-14.
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12. Finney JMT. The opportunities and responsibilities of the surgeon. Ann Surg 1922;76:293-307. 13. Mueller CB, Evarts A. Graham: the life, lives, and times of the surgical spirit of St. Louis. Hamilton: BC Decker; 2002. 14. Cutler EC. Undergraduate teaching of surgery. Ann Surg 1935;102:507-15. 15. Archibald EW. Higher degrees in the profession of surgery. Ann Surg 1935;102:481-95. 16. Grillo HC, Edward D. Churchill, MD: a founding father of thoracic surgery. J Cardiovasc Surg 1996;37(1 Suppl): 21-9. 17. Churchill ED. Personal and biographical memoirs. Taped interviews by S. Benison. Countway Library of Medicine, archives. Boston. Box 71, folders 17-25. 18. Churchill ED. Graduate training at the Massachusetts General Hospital: a report to the trustees from the general executive committee. Boston; 1939. 19. Massachusetts General Hospital, General Executive Committee minutes. 1939;33:97. Claflin Library, MGH, Boston. 20. Churchill ED. Graduate training in surgery at the Massachusetts General Hospital. Harv Med Alum Bull 1940;14: 28-36. 21. Carter BN. The fruition of Halsted’s concept of surgical training. Ann Surg 1997;225:445-58. 22. Sealy WC. Halsted is dead: time for change in graduate surgical education. Curr Surg 1999;56:34-9. 23. Churchill ED. Medical education. Harv Med Alum Bull 1946;21:15-7. 24. Churchill ED. In: Scannell JG, editor. Wanderjahr: the education of a surgeon. Boston: Countway Library; 1990.
SURGERY NOVEMBER 2004
Historical paper Edward D. Churchill and the ‘‘rectangular’’ surgical residency Hermes C. Grillo, MD, Boston, Mass
From the Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
SURGICAL TRAINING IN THE UNITED STATES was limited, ungraded, and of apprentice character until the introduction by William Halsted in 1889 of a transformational progressive and science-based but steeply pyramidal program, adapted from the German model. A single individual might emerge as a fully trained, potential professor of surgery after prolonged and intensive apprenticeship. In a second transformational point, after establishment of national standards for complete surgical training by the new American Board of Surgery (ABS) in 1937, Edward Delos Churchill formulated a ‘‘rectangular’’ program of residency to provide complete training to a smaller number of candidates, emphasizing peer group education in a school of surgery, not dominated by a single individual. THE HALSTED RESIDENCY AND ITS INFLUENCE The surgical training program instituted at Johns Hopkins by Halsted in 1889 was new to the United States. Halsted had been greatly impressed during his European studies by the proficiency,
Accepted for publication September 13, 2004. Reprint requests: Hermes C. Grillo, MD, Massachusetts General Hospital, Blake 1570, 55 Fruit Street, Boston, MA 02114. Surgery 2004;136:947-52. 0039-6060/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.surg.2004.09.002
depth of understanding, and wealth of experience of German surgeons. The system of training that he designed at Hopkins was closely modeled on the German plan.1 William Osler, also influenced by German scientific medicine, said that Halsted had come back from Germany very much ‘‘verdeutsched, and held that there were only three or four good surgeons in the world and all of them were German.’’2 Halsted’s belief was that ‘‘the hospital, the operating room and the wards should be laboratories, laboratories of the highest order, and we know from experience that where this conception prevails, not only is the cause of higher education and of medical science best served, but also the welfare of the patient is best promoted.’’ He stated that to accomplish these goals, ‘‘We need a system, and we will surely have it, which will produce not only surgeons but surgeons of the highest type, men who will stimulate the first youths of our country to study surgery and to devote their energies and their lives to raising the standard of surgical science.’’1 Eight interns were selected yearly by Halsted. Four stayed only one year and four remained for various terms. One became house surgeon, with the other three more or less in line for preferment. Staff vacancies occurred for these men only rarely. Their advancement was not guaranteed. Halsted proudly remarked that his applicants would gladly serve ten years for this opportunity. He believed that their zeal only increased with the passing of the years. He intended to adopt ‘‘as closely as SURGERY 947
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feasible the German plan.’’ He hoped that these top graduates would become professors of surgery at leading medical schools. Will Sealy, trained in the Hopkins tradition at Duke, concluded as follows: ‘‘What are the characteristics of the GermanHalsted-Hopkins system? It is a strict pyramid with an autocratic chief. . The period of training is long and indefinite.’’3 The example of the Halsted residency and the superior surgeon it produced led many centers to follow suit.4 Among these were Yale, the Peter Bent Brigham in Boston, and Duke. The professors of surgery in each of these institutions were Halstedtrained. The steeply pyramidal system of surgical residency did not then appear disadvantageous because men who had only two or three years of such training could return to their communities already more knowledgeable than most in the art and science of surgery. The example of Johns Hopkins, however, did not immediately effect universal change in surgical education in the United States. At the University of Pennsylvania, for example, a two-year rotating internship was required by law. ‘‘Up until 1922, a person desiring to go into surgery more or less apprenticed himself to a staff surgeon as his assistant and gradually built up a practice of his own on whatever crumbs fell from the table,’’ wrote Dr. Jonathan E. Rhoads.5 In 1925, Professor Charles H. Frazier created a system of three-year surgical fellowships at that hospital. In addition to clinical duties, the fellows were granted time to do research, and indeed, this was expected of them.6 At Massachusetts General Hospital (MGH), surgical training had increased to three years by 1935, but the young surgeon was still not prepared for independent practice, unlike the single resident who did reach the apex of the Hopkins pyramid. Further evolution of surgical training awaited the imposition of external national standards. Ultimately, as Churchill wrote, ‘‘The traditional manner by which the practical art was passed down from dominant master to docile apprentice underwent conversion to an interchange of knowledge between teacher and pupil.’’7 NATIONAL STANDARDS FOR SURGICAL EDUCATION The American Medical Association, spurred by the efforts of Arthur Dean Bevan of Rush, supported improvements in medical education proposed in the Flexner report in 19078 but resisted setting specialty standards in deference to its constituency of practitioners, who wished to continue to perform surgery without restriction.
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The elite American Surgical Association (ASA) at first showed little interest in working to raise the standards of American surgery beyond academic institutions. It was left to the American College of Surgeons (ACS), which had been formed under Franklin Martin in 1910, to strive effectively to elevate surgical standards in the United States, chiefly by the mechanism of demanding higher hospital standards.9 A survey of hospitals in 1919 found that only 89 of 671 met the college’s minimal criteria. Individual membership standards initially set by the college were also quite low, but this recognized that no higher standards would have been acceptable at that time. Requirements for fellowship in the ACS were indeed modest: (1) a year’s internship, usually rotating; (2) two years as an assistant under a preceptor; (3) visits to surgical clinics; and (4) submission of a list of fifty consecutive operations. After 1920, graduation from an approved medical school was added! The intriguing story of recognition of need for stricter standards for all surgeons has been told in detail.10,11 J.M.T. Finney, as president of the ASA, but who had also served as first president of the ACS, called for united effort by all surgical organizations to improve training and certification of surgeons.12 The call went unheeded. Evarts Graham, professor of surgery at Washington University, was gravely concerned about the state of surgical practice. He was critical of the lax standards of the ACS but was drawn into that organization against his will. He endeavored to bring younger surgical leaders into positions of influence in the ACS but was frustrated.10,11,13 When George Heuer, Elliot Cutler, and Allen Whipple, who had been appointed by the regents of the ACS as a committee to study surgical education, were denied the floor at the ACS for their report, they sought a forum at the ASA. Cutler, speaking of the often poorly trained practitioner of surgery, declared in indignation, ‘‘We permit this untrained individual to practice his art upon, let us be frank, the unsuspecting public.’’14 At that meeting, President Edward Archibald appealed for a system of instruction and examination for surgical qualification.15 Graham chaired the committee that resulted from this call for action. This led directly to the formation of an independent qualifying board in 1937. The board’s training requirements for examination evolved gradually. The board declared that ‘‘technical training under supervision in an institution must replace unsupervised experience obtained in private practice at the expense of an unsuspecting public.’’ A decade later the board made a senior year of institutional training
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mandatory, and preceptorships were effectively ended. Major changes in surgical training were necessary. THE CHURCHILL PLAN FOR RESIDENCY Edward D. Churchill (Fig 1) became chief of the West Surgical Service at MGH in 1931.16 He was appreciative of the skills and contributions of older surgeons but was critical of the master-apprentice mode of surgical training still current. He was troubled by the ‘‘anti-intellectual, anti-scientific’’ bias of senior surgeons, noting that ‘‘attitudes change slowly when a practical art is being passed along from master to neophyte.. [T]heir minds had crystallized.’’17 He believed that ‘‘the Halsted residency at the Hopkins . was a modified masterapprentice relationship. It was more subtle; more independence was granted to the apprentice.. nevertheless, the Halsted resident looked up to one man and one man alone.’’17 Churchill later explained, ‘‘At the MGH, I have tried to perpetuate the school concept of a group of masters, in which no single personality dominates the methods and the technology of the institution.’’17 He further wished to obviate the subservient status of the trainee under a quasi-parental, self-aggrandizing, and authoritarian tutelage, which could be so much a part of apprenticeship. ‘‘We don’t want a man to be trained under a single master, for therein lies a danger.’’18 In retrospective appraisal, he later stated: ‘‘The conversion of the intellectually sterile master-apprentice situation into a mutually stimulating teacher-pupil relationship has been one of the goals of my professional life.’’17 He noted that although the master may not relish seeing his apprentice mature, the teacher finds pleasure in watching his pupil grow. He deplored the prolonged period of servitude as assistants to older surgeons as ‘‘wastage of their vigorous and creative years of youth.’’ Churchill’s vision of a pattern for such a surgical school found expression in what was called ‘‘the Churchill Plan.’’18,19 He quoted president of Harvard A. Lawrence Lowell’s praise of the benefit of a pattern in ‘‘distinguishing the essential elements . from the accessories’’ in a plan. ‘‘Such a pattern,’’ Lowell wrote, ‘‘is by no means rigid; the final objective is perfectly definite, but the details are fluid and must be kept so throughout.. [I]f the pattern is sound, it should not be injured by changes in detail.’’ Churchill recognized a weighty institutional obligation to trainees. ‘‘The willingness of this group to deliver themselves up to an institution for four to six years of the most vital period of their life
Fig 1. Edward Delos Churchill (1895-1972), John Homans Professor of Surgery at Harvard and chief of the surgical services (1931-1962) at Massachusetts General Hospital. Photograph dates from about the time of the 1939 report (author’s collection).
without any commitment for the ultimate future places a grave responsibility on the hospital to give them the best it has.’’18 He emphasized the need to distinguish ‘‘between what is essential and what might be useful, but is not essential.’’ Needless prolongation of training was to be avoided. He saw little value for future specialists in a preliminary rotating internship. In 1940, only 3% of US hospitals offered ‘‘straight’’ internships. Churchill felt that careful diagnostic thinking and attention to preoperative and postoperative care would suffice to provide the needed medical background for a surgical trainee. PRINCIPLES OF TRAINING Dr Churchill underlined principles that should govern the curriculum.18 1. Exploitation of the intern by ‘‘repetitious performance of routine procedures’’ was to be avoided. He cited Whitehead’s caution that ‘‘prolonged routine work dulls the imagination’’
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3.
4.
5.
Fig 2. Diagram of the then current residency program (‘‘present’’) contrasted with the proposed new program, reproduced from the original report authored by Dr. Churchill and submitted to the trustees of the Massachusetts General Hospital in 1938.18 The then conventional 2-year program accepted 8 candidates, indicated by the vertical bars, only 2 of whom were allowed a further 2 years of training. Time scale in years at the left. This was a sharply fashioned ‘‘pyramid.’’ The new ‘‘rectangular’’ program (‘‘proposed’’) selected 6 candidates but offered all of them a complete surgical training (initially 4.5 years, quickly modified to 5 years). Two were offered a further supervisory year of education, which might provide preparation for an academic post. Gaps in the proposed program indicate possible elective periods.
and the more general wisdom that ‘‘necessary technical excellence can only be acquired by training which is apt to damage those energies of mind which should direct the technical skill.’’ 2. He agreed with the ABS and Halsted’s insistence on the need for exposure to basic science, distinguishing this carefully, however, from research on an original problem. This recognized that surgery was now based on laboratory sciences such as bacteriology and physiology, in addition to an earlier basis in anatomy and pathology. Churchill soon felt that basic sciences applicable to surgery were best learned in the course of surgical training itself rather than in discrete periods of instruction. He recognized that only a few men were likely to desire a prolonged period of original research. He declared, ‘‘Others desiring to attain excellence as practitioners of surgery will not be required
6.
to do penance in experimental laboratories in order to secure advanced clinical training.’’ Flexibility and tailoring to individuals was to be sought. Said Churchill, ‘‘A frozen five-year curriculum. is unthinkable as it allows no latitude for the development of individual interests and proficiencies.’’20 Staff appointments were to be ‘‘held by mature and well-qualified surgeons, willing to devote time and effort to the training of residents.’’ Responsibility of the trainee must be increased ‘‘as the individual proves himself competent to take it on his shoulders.’’ In this Churchill confirmed the principle of graded responsibility espoused by Halsted and the ABS. Lack of progressive responsibility was a defect in the apprentice system. Previously, young surgeons had completed their technical training as junior members of the staff. Lengthening the training program must lead to increased responsibility—‘‘a fundamental necessity in their education’’—and must be graded experience. An advisory board for graduate education was necessary to avoid ‘‘cumulative warping of the structure of the educational program’’ by ‘‘a series of minor changes, each judged in terms of what is immediately expedient for the care of the sick or the convenience of the administrative or professional staff.’’
The proposed program would take fewer candidates each year but keep them longer (Fig 2). The previous steep ‘‘pyramid,’’ in which only two trainees would receive four years of training, even then not calculated to prepare them for independent surgical practice, would be exchanged for five years of training for all accepted candidates. The training was calculated to provide complete surgical preparation to enable each graduate to begin surgical practice. Two would receive an extra supervisory year. These two might aim to be professors, but not necessarily. Continuation in the program was conditional, of course, on good performance and a desire to complete it. Specialty rotations were intended to teach diagnostic principles and specialty techniques rather than to impart surgical proficiency in the specialty. Emphasis on operative techniques in general surgery would begin in the second year. It was hoped that the first three years might also serve as a preparation for surgical specialties. The five-year program would provide complete training for ABS certification. The resident surgeon (later chief resident and now staff surgeon) was intended to serve as the ‘‘executive head’’ of the service, under the visiting staff, with additional obligations for
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undergraduate teaching. Churchill noted the eventual need for special funds for residents wishing to take a year or more (never less) for original investigation. The heart of the plan, of course, was substitution of a ‘‘rectangular’’ plan of resident development for the previously dominant pyramid. The pyramid might have seemed to be the best structure for a hospital selfishly, by eliminating lessfavored trainees year by year. They were sacrificed in order to polish one or two individuals, who obtained intensive operative experience in a final year or two. This served very well to produce potential professors.21 It also sent a large group of inadequately trained surgeons into practice and incidentally increased the ‘‘gross tonnage of output of laboratories’’—not necessarily of high quality. In Churchill’s words, ‘‘Half a surgical training is about as useful as half a billiard ball.’’ The rectangular plan was based on confidence that by and large candidates could be selected in their fourth year of medical school with sufficient accuracy so that they could complete a five-year training program with credit. The distraction of fierce competition for survival from year to year would be removed, allowing the residents to concentrate on their education in cooperative fashion. Churchill believed that both future professors and practitioners required similar surgical education in depth. The academically minded might add a period of scientific research, but both groups would be equally sound clinicians. Churchill often stated that he was as proud of his graduates who were practicing surgeons in a community as he was of those who became professors—and there were many in both categories. Implementation of the proposed reorganization was largely deferred by the onset of World War II. The entering class of 1946 was the first to move through the new system completely in accordance with the plan. Upper echelons of the residency staff were filled by returning veterans, but the essence of the program had changed. CONSEQUENCES OF THE PROGRAM With relatively minor adjustments, the Churchill plan proved to be highly successful. (1) It succeeded in giving complete training to superior surgeons, (2) it eliminated the human wastefulness of the pyramidal system, and (3) it responded to the nation’s surgical needs after World War II. In a time of change, this approach to residency training achieved wide recognition and was influential in redesign of surgical residency programs nationally.22 The pyramidal system was soon
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abandoned. The Halsted system had indeed revolutionized American surgical education fifty years previously, but surgical and societal needs were now better met by the rectangular model, directed by changes in educational philosophy and attitude. Dr. Churchill always expressed concern about the fragmentation of surgery by specialization. He defined specialism as of two types: (1) the acquisition of skill in applying already standardized techniques, and (2) concentration in a field in which new techniques and principles may arise, which are transferable to or from other fields. He wished to encourage concentration. ‘‘A concentrator seeks to maintain an active curiosity and interest concerning all techniques that might be useful in his area of concentration, and views his work in proper perspective with science as a whole.’’23 He regarded narrow specialism as self-limiting, ‘‘myopic,’’ and dulling to the intellect. His well-known resistance to subdivision of general surgery stemmed from these convictions. Nonetheless, Churchill showed the flexibility he espoused. Thus, he readily accepted specific changes in resident specialty assignments in the 1960s, which were justified by increasing volumes and complexity of cases. Edward Churchill approved of the fundamental changes his program had wrought. ‘‘The greatest change in this program came between . 1940 and 1960.. If I were to sum it up in one sentence, I would say the transition [was] from the classical and ancient master-apprentice training to a more contemporary age–peer group educational effort.’’ Churchill wrote, ‘‘Our whole program in graduate education. is to keep the framework flexible and adapt it to the needs and interests of the individual. If technical training dominates these years of a young surgeon’s life, he will emerge as a pure technician. It is very essential that he be taught to understand the nature of the tools that he is using, and develop a critical judgment in regard to new procedures and new tools, not merely attain proficiency in existing techniques.’’24 The ‘‘pattern’’ of the Churchill residency has stood the test of time extraordinarily well. It has served as a model, consciously or unconsciously, for modification of surgical education throughout the United States. As we consider altering our present surgical programs to meet perceived social needs and technological change, we shall do well to remember the fundamental educational principles of Halsted and Churchill and the historical evolution that brought us to this point. A fundamental principle that must remain is commitment to the educational needs of our students, who shall also be
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our successors, and concurrently to the best interests of the patients for whom we both care.
REFERENCES 1. Halsted WS. The training of the surgeon. Johns Hopkins Hosp Bull 1904;15:267-75. 2. Bordley J III, Harvey AM. Two centuries of American medicine 1776-1996. Philadelphia: WB Saunders; 1976. 3. Sealy WC. Residents and residencies. Ann Thorac Surg 1971;12:561-73. 4. Cameron JL. William Stewart Halsted: our surgical heritage. Ann Surg 1997;225:445-58. 5. Rhoads JE. Personal communication, May 22, 1998. 6. Corner CW. Two centuries of medicine: a history of the School of Medicine, University of Pennsylvania. Philadelphia: Lippincott; 1965. p. 278-9. 7. Churchill ED. Origins of American surgery. JAMA 1960;172: 219-22. 8. Flexner A. Medical education in the United States and Canada. Bulletin 4. Carnegie Foundation for the Advancement of Teaching. Boston: Merrymount Press; 1910. 9. Davis L. Fellowship of surgeons: American College of Surgeons. Chicago: Charles C. Thomas; 1960. 10. Olch PD. Evarts Graham, the American College of Surgeons and the American Board of Surgery. J Hist Med 1972;27: 247-61. 11. Grillo HC. To impart this art: The development of graduate surgical education in the United States. Surgery 1999;125: 1-14.
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12. Finney JMT. The opportunities and responsibilities of the surgeon. Ann Surg 1922;76:293-307. 13. Mueller CB, Evarts A. Graham: the life, lives, and times of the surgical spirit of St. Louis. Hamilton: BC Decker; 2002. 14. Cutler EC. Undergraduate teaching of surgery. Ann Surg 1935;102:507-15. 15. Archibald EW. Higher degrees in the profession of surgery. Ann Surg 1935;102:481-95. 16. Grillo HC, Edward D. Churchill, MD: a founding father of thoracic surgery. J Cardiovasc Surg 1996;37(1 Suppl): 21-9. 17. Churchill ED. Personal and biographical memoirs. Taped interviews by S. Benison. Countway Library of Medicine, archives. Boston. Box 71, folders 17-25. 18. Churchill ED. Graduate training at the Massachusetts General Hospital: a report to the trustees from the general executive committee. Boston; 1939. 19. Massachusetts General Hospital, General Executive Committee minutes. 1939;33:97. Claflin Library, MGH, Boston. 20. Churchill ED. Graduate training in surgery at the Massachusetts General Hospital. Harv Med Alum Bull 1940;14: 28-36. 21. Carter BN. The fruition of Halsted’s concept of surgical training. Ann Surg 1997;225:445-58. 22. Sealy WC. Halsted is dead: time for change in graduate surgical education. Curr Surg 1999;56:34-9. 23. Churchill ED. Medical education. Harv Med Alum Bull 1946;21:15-7. 24. Churchill ED. In: Scannell JG, editor. Wanderjahr: the education of a surgeon. Boston: Countway Library; 1990.