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Forging the surgical “cookie-cutter”
Forging
the Surgical
“Cookie-Cutter”
WILLIAM G. ANLYAN, M.D. ANDEUGENE A. STEAD, M.D., Durham,
as a discipline is at the crossroads, S URGERY Should surgical education in the future be
North Carolina
tioner, a community specialist, or an academician. At Duke it is planned to institute a new curriculum with such a “core” program for the first two years (one year preclinical, one year clinical). The second two year period would be spent in a tailored program designed to develop a better general practitioner, a more adept community specialist, or an academician with a stronger foundation in the basic sciences. Thus, the potential surgical academician (e.g., with a special interest in homotransplantation) would have included in his last two years in medical school immunogenetics, immunopathology, and renal physiology for his third year, and related clinical areas in his fourth year. His research program would be initiated at the end of his second year under the joint tutorship of the basic science investigator and the clinician with special interests in the field of transplantation. To go back to the analogy with aviation, unlike the days of the Wright Brothers or the Flexner report, one cannot expect an individual today to be the designer, builder, pilot, etc., of our air and space craft. Hence the opportunity for earlier development in depth of special interests should be made available. There would undoubtedly be a significant number of undergraduate medical students who would be undecided with regard to special interests; in such instances, the individual’s schedule would be tailored to encompass a broader but more superficial course of study. Beyond medical school, the internship experience would, for the present, remain essentially unchanged. The two years of obligatory military service will probably be with us for some time to come; every effort should be made to place the potential surgical leader in a military assignment where he can further his ability to create new knowledge. In the ensuing four or five years of residency at least one year should be devoted to full-time research, and in the
directed at undergraduate as well as graduate and postgraduate students of medicine? Should the field of surgery embrace not only the surgical care of patients but also its position as a science? What “retooling” is necessary to ensure that surgical education will provide the necessary curriculum to develop potential surgical scientists? The key person to determine the future path of surgery is the surgical “cookie-cutter” or the academic surgeon of the coming generation. He will set the mold not only for the academic surgeon of the future who may or may not create new knowledge but also determine the scope of activity of the practicing community surgeon who will apply the new knowledge. In thinking about the forging of the surgical cookie-cutter, one has to be realistic about the recent revolutionary developments in the physical and biologic sciences. One cannot afford to be a traditionalist; what was an effective training program for the past three decades may be outmoded today. In an era when air travel has made the transition from the DC-3 to the Friendship VII spacecraft, we cannot turn our backs to the future by adhering to the old dependable ways. The rate of creation of new knowledge in the biologic sciences makes it imperative to take a look at the mold for the surgical leader of the future. In developing this “mold,” a few problems must be acknowledged. No one person can master all of the basic science and clinical information currently available in four years of medical school. The advances in each field are developing by geometric progression. Therefore, it is essential to filter out and select a “core” of information which will be useful to a potential medical school graduate irrespective of whether he is to become a general practi106
American
Journal
of Surgery
Forging the Surgical “Cookie-Cutter” remaining years assurance of part-time participation in the laboratory should be given. It is the classical error in educational planning today that every man in a residency program must spend the same amount of time on each rotation to get the same quantity of experience. Undoubtedly, the brilliant young trainee may, after managing twenty-five patients requiring surgery for peptic ulcer, acquire twice the knowledge that the average trainee derives after fifty cases. However, we must state emphatically that we have no intent to produce a brilliant laboratory investigator who has had a meager clinical experience and who is not equally respected by his colleagues as a clinician. Thus, in the five year residency period the potential cookie-cutter has had the opportunity to develop the necessary tools to create new knowledge and at the same time become a clinician of equal ability as his colleague who is to spend his lifetime applying new knowledge. Why not defer the laboratory experience till the end of a formal residency program? It is too late ! At an average age of thirty-three years (twelve years after graduation from college) the emerging surgical resident is too old to begin to master the tools of modern basic research. Most Nobel laureates earn their prizes for work accomplished in their twenties and thirties. At the age of thirty-three, the socioeconomic pressures of a family and the length of the gap from his previous basic science experience would discourage the surgical resident from returning to the basic sciences and the fields of mathematics, statistics, and computers -areas that had continued to develop while he was a surgical embryo. What about the surgical specialties? Is there a difference in molding the “cookie-cutter” for neurosurgery, or othopedics, urology? Also, can our current specialists help mold the “generalist?” The same type of educational program planning would evolve. Thus the potential professor of neurosurgery may or may not recognize his interest after the “core” program of the first two years of medical school. If the decision is an early one, the tailoring of his third year would include neurochemistry, neurophysiology, neuropharmacology, and neuropathology. In his fourth year on the clinical services, a substantial rotation on medical neurology would be included. He would have initiated a research relationship with one of the basic science areas in his third year. After his Vol. 110, July
1965
107
straight surgical internship and two years in the Armed Services (hopefully at the National Institutes of Health or a similar establishment) he would return to a four or five year residency program in which a portion of his time would be jealously guarded for a continuation of his laboratory endeavors to create new knowledge. To the second question regarding the capability of the surgical specialist in providing a “general” education, the answer is “definitely yes.” The surgical specialist of today and of the future should be thoroughly competent in teaching the fundamental principles of surgery at the undergraduate and graduate medical levels. Wound healing, infections, trauma, fluid, and electrolyte disturbances are examples of areas that are common to all surgeons and surgical educators. Another problem that we encounter today is at what point is training and surgical education complete? The answer should be “never”; no “cookie-cutter” can turn out a finished and experienced product. That education is a continuing and life-long endeavor must be firmly instilled in the “baking.” There is here, though, a slight difference between the future academician and the practicing community specialist. The newly sprouted academician may have a more formal continuing education by his constant exposure to his colleagues who have knowledge in depth in areas currently deficient in the neophyte’s education. The practicing specialist, on the other hand, has less opportunity to participate in daily continuing education ; therefore, at the end of his residency he should have achieved an exposure sufficiently extensive to allow him to make correct judgments on his own. As a corollary, he should be keenly aware of his limitations since the “rescue squad” of experienced colleagues is less readily available. Finally, the reader who is a practicing community surgeon might ask: “This is fine, but how will the molding of the future professor of surgery affect the quality of surgical practice in my community?” To answer this very ligitimate query, one should look back at our surgical heritage. Halsted, Matas, Phemister, Whipple (in alphabetical order) were examples of “surgical cookie-cutters”; their mold was useful not only in turning out eminent surgical professors but equally important in producing outstanding community specialists of the highest order. It is hoped that this type of mold for the
108
Anlyan
surgical academician of the future would ensure the field of surgery the maintenance of its position as a science in a world in which, allegedly, 90 per cent of the scientists ever to exist are alive today. SURGERY
AS SEEN FROM THE VANTAGE
POINT OF A DEPARTMENT
OF MEDICINE*
It is always easier to solve other people’s problems than one’s own. With this note of humility, I will summarize what I think are the current errors in the educational programs of my surgical colleagues. 1. There is a lack of appreciation of the fact that surgeons do not do research as surgeons. Their role as surgeons gives them access to operating room facilities and patients. To use these facilities for research, they must have training in one or more of the traditional scientific disciplines. Training must extend beyond the limits of the Department of Surgery. This applies equally well to departments of medicine. Our role as internists gives us access to patients but we do not do research as internists. We use the tools of physiology, biochemistry, biophysics, mathematics, psychology, and sociology. 2. The heads of surgical divisions are too lazy to plan programs which may make the service a little harder to run but which would save time for their residents. They too often want the man to be completely deferred for training, or to start his real work after an in* Additional comments by Dr. Stead.
and Stead different year .of internship and after two years of general work in the Armed Services. Obtaining scientific training outside of surgery is sacrificed for the convenience of the service. A research appointment in a biochemical or physiologic laboratory at the National Institutes of Health is worth more than any particular sequence of rotations through any surgical service. 3. The resident at the end of his training must be a complete surgeon, never again requiring help from man or beast. It is clear that, under this philosophy, formal training can go on forever. The young surgeon should be able to master an area sufficient to allow him to earn his bread and butter. Enlargement of his area of clinical competence and his development as a scientist can then go on hand-in-hand. It never really hurts one to ask for help. 4. There is not enough excitement on surgical services outside the operating room. Fascinating problems involving most aspects of biology are present in abundance, but there is no one around to involve the students, interns, and residents in looking into them. The surgeons need to have a nonoperating team working the wards at all times of day and night. This can be done entirely by the surgeons or it can be implemented by a series of joint appointments with the medical staff. Dr. Anlyan and I have discussed these problems at length, and his essay gives some practical solutions to my theoretic considerations of the problem.
American Journal of Surgery
the Surgical
“Cookie-Cutter”
WILLIAM G. ANLYAN, M.D. ANDEUGENE A. STEAD, M.D., Durham,
as a discipline is at the crossroads, S URGERY Should surgical education in the future be
North Carolina
tioner, a community specialist, or an academician. At Duke it is planned to institute a new curriculum with such a “core” program for the first two years (one year preclinical, one year clinical). The second two year period would be spent in a tailored program designed to develop a better general practitioner, a more adept community specialist, or an academician with a stronger foundation in the basic sciences. Thus, the potential surgical academician (e.g., with a special interest in homotransplantation) would have included in his last two years in medical school immunogenetics, immunopathology, and renal physiology for his third year, and related clinical areas in his fourth year. His research program would be initiated at the end of his second year under the joint tutorship of the basic science investigator and the clinician with special interests in the field of transplantation. To go back to the analogy with aviation, unlike the days of the Wright Brothers or the Flexner report, one cannot expect an individual today to be the designer, builder, pilot, etc., of our air and space craft. Hence the opportunity for earlier development in depth of special interests should be made available. There would undoubtedly be a significant number of undergraduate medical students who would be undecided with regard to special interests; in such instances, the individual’s schedule would be tailored to encompass a broader but more superficial course of study. Beyond medical school, the internship experience would, for the present, remain essentially unchanged. The two years of obligatory military service will probably be with us for some time to come; every effort should be made to place the potential surgical leader in a military assignment where he can further his ability to create new knowledge. In the ensuing four or five years of residency at least one year should be devoted to full-time research, and in the
directed at undergraduate as well as graduate and postgraduate students of medicine? Should the field of surgery embrace not only the surgical care of patients but also its position as a science? What “retooling” is necessary to ensure that surgical education will provide the necessary curriculum to develop potential surgical scientists? The key person to determine the future path of surgery is the surgical “cookie-cutter” or the academic surgeon of the coming generation. He will set the mold not only for the academic surgeon of the future who may or may not create new knowledge but also determine the scope of activity of the practicing community surgeon who will apply the new knowledge. In thinking about the forging of the surgical cookie-cutter, one has to be realistic about the recent revolutionary developments in the physical and biologic sciences. One cannot afford to be a traditionalist; what was an effective training program for the past three decades may be outmoded today. In an era when air travel has made the transition from the DC-3 to the Friendship VII spacecraft, we cannot turn our backs to the future by adhering to the old dependable ways. The rate of creation of new knowledge in the biologic sciences makes it imperative to take a look at the mold for the surgical leader of the future. In developing this “mold,” a few problems must be acknowledged. No one person can master all of the basic science and clinical information currently available in four years of medical school. The advances in each field are developing by geometric progression. Therefore, it is essential to filter out and select a “core” of information which will be useful to a potential medical school graduate irrespective of whether he is to become a general practi106
American
Journal
of Surgery
Forging the Surgical “Cookie-Cutter” remaining years assurance of part-time participation in the laboratory should be given. It is the classical error in educational planning today that every man in a residency program must spend the same amount of time on each rotation to get the same quantity of experience. Undoubtedly, the brilliant young trainee may, after managing twenty-five patients requiring surgery for peptic ulcer, acquire twice the knowledge that the average trainee derives after fifty cases. However, we must state emphatically that we have no intent to produce a brilliant laboratory investigator who has had a meager clinical experience and who is not equally respected by his colleagues as a clinician. Thus, in the five year residency period the potential cookie-cutter has had the opportunity to develop the necessary tools to create new knowledge and at the same time become a clinician of equal ability as his colleague who is to spend his lifetime applying new knowledge. Why not defer the laboratory experience till the end of a formal residency program? It is too late ! At an average age of thirty-three years (twelve years after graduation from college) the emerging surgical resident is too old to begin to master the tools of modern basic research. Most Nobel laureates earn their prizes for work accomplished in their twenties and thirties. At the age of thirty-three, the socioeconomic pressures of a family and the length of the gap from his previous basic science experience would discourage the surgical resident from returning to the basic sciences and the fields of mathematics, statistics, and computers -areas that had continued to develop while he was a surgical embryo. What about the surgical specialties? Is there a difference in molding the “cookie-cutter” for neurosurgery, or othopedics, urology? Also, can our current specialists help mold the “generalist?” The same type of educational program planning would evolve. Thus the potential professor of neurosurgery may or may not recognize his interest after the “core” program of the first two years of medical school. If the decision is an early one, the tailoring of his third year would include neurochemistry, neurophysiology, neuropharmacology, and neuropathology. In his fourth year on the clinical services, a substantial rotation on medical neurology would be included. He would have initiated a research relationship with one of the basic science areas in his third year. After his Vol. 110, July
1965
107
straight surgical internship and two years in the Armed Services (hopefully at the National Institutes of Health or a similar establishment) he would return to a four or five year residency program in which a portion of his time would be jealously guarded for a continuation of his laboratory endeavors to create new knowledge. To the second question regarding the capability of the surgical specialist in providing a “general” education, the answer is “definitely yes.” The surgical specialist of today and of the future should be thoroughly competent in teaching the fundamental principles of surgery at the undergraduate and graduate medical levels. Wound healing, infections, trauma, fluid, and electrolyte disturbances are examples of areas that are common to all surgeons and surgical educators. Another problem that we encounter today is at what point is training and surgical education complete? The answer should be “never”; no “cookie-cutter” can turn out a finished and experienced product. That education is a continuing and life-long endeavor must be firmly instilled in the “baking.” There is here, though, a slight difference between the future academician and the practicing community specialist. The newly sprouted academician may have a more formal continuing education by his constant exposure to his colleagues who have knowledge in depth in areas currently deficient in the neophyte’s education. The practicing specialist, on the other hand, has less opportunity to participate in daily continuing education ; therefore, at the end of his residency he should have achieved an exposure sufficiently extensive to allow him to make correct judgments on his own. As a corollary, he should be keenly aware of his limitations since the “rescue squad” of experienced colleagues is less readily available. Finally, the reader who is a practicing community surgeon might ask: “This is fine, but how will the molding of the future professor of surgery affect the quality of surgical practice in my community?” To answer this very ligitimate query, one should look back at our surgical heritage. Halsted, Matas, Phemister, Whipple (in alphabetical order) were examples of “surgical cookie-cutters”; their mold was useful not only in turning out eminent surgical professors but equally important in producing outstanding community specialists of the highest order. It is hoped that this type of mold for the
108
Anlyan
surgical academician of the future would ensure the field of surgery the maintenance of its position as a science in a world in which, allegedly, 90 per cent of the scientists ever to exist are alive today. SURGERY
AS SEEN FROM THE VANTAGE
POINT OF A DEPARTMENT
OF MEDICINE*
It is always easier to solve other people’s problems than one’s own. With this note of humility, I will summarize what I think are the current errors in the educational programs of my surgical colleagues. 1. There is a lack of appreciation of the fact that surgeons do not do research as surgeons. Their role as surgeons gives them access to operating room facilities and patients. To use these facilities for research, they must have training in one or more of the traditional scientific disciplines. Training must extend beyond the limits of the Department of Surgery. This applies equally well to departments of medicine. Our role as internists gives us access to patients but we do not do research as internists. We use the tools of physiology, biochemistry, biophysics, mathematics, psychology, and sociology. 2. The heads of surgical divisions are too lazy to plan programs which may make the service a little harder to run but which would save time for their residents. They too often want the man to be completely deferred for training, or to start his real work after an in* Additional comments by Dr. Stead.
and Stead different year .of internship and after two years of general work in the Armed Services. Obtaining scientific training outside of surgery is sacrificed for the convenience of the service. A research appointment in a biochemical or physiologic laboratory at the National Institutes of Health is worth more than any particular sequence of rotations through any surgical service. 3. The resident at the end of his training must be a complete surgeon, never again requiring help from man or beast. It is clear that, under this philosophy, formal training can go on forever. The young surgeon should be able to master an area sufficient to allow him to earn his bread and butter. Enlargement of his area of clinical competence and his development as a scientist can then go on hand-in-hand. It never really hurts one to ask for help. 4. There is not enough excitement on surgical services outside the operating room. Fascinating problems involving most aspects of biology are present in abundance, but there is no one around to involve the students, interns, and residents in looking into them. The surgeons need to have a nonoperating team working the wards at all times of day and night. This can be done entirely by the surgeons or it can be implemented by a series of joint appointments with the medical staff. Dr. Anlyan and I have discussed these problems at length, and his essay gives some practical solutions to my theoretic considerations of the problem.
American Journal of Surgery