Foreword G a s t r i c Su r g e r y
Ronald F. Martin, MD Consulting Editor
Generally speaking, the forewords to each issue of the Surgical Clinics of North America are written with the intent of informing the reader as to why we have incorporated this particular set of topics into the series. For most surgeons it would appear somewhat self-evident as to the importance of the topic of Gastric Surgery to the overall understanding one must have to be a competent general surgeon. With that in mind, I should not like to insult the reader’s intelligence by restating the obvious, but rather use this opportunity to consider what other examples we may take from this theme that might help us on larger questions. Two particular topics come to mind: the evolution of inquiry, and facts trumping beliefs. I have written before, and still maintain, that the evolution of understanding of gastric anatomy and physiology, coupled with our ability to alter both structure and function by operative and nonoperative means, may be the best example of how surgeons think when they think best. I harbor no desire to belittle any of the contributions of other surgical endeavors, such as cardiac surgery, operative orthopedics, neurosurgery, operative endoscopy, or any of the others, but still, in my opinion, the development of gastric surgery is our crown jewel. The reasons are many-fold perhaps, but among them are its development was more-or-less first and therefore set the stage for many to follow in terms of intellectual rigor. Also, the principles studied have been reevaluated and modified and tested by means that we could measure fairly accurately. Last, but not exhaustively, we have modified and corrected our approach based upon changing circumstances and new technology, both operative and pharmaceutical, from the very beginning of the study of these topics in the latter 1800s. We have let ourselves be guided by facts inasmuch as we could understand them. So we now find ourselves in 2011. In particular, we find ourselves in 2011 in the month of July at the writing of this foreword. What is peculiar about this month may not be evident to all, but the discipline of surgery in the United States has just experienced perhaps the most seismic event it has seen for some time. We have created two fundamentally distinct classes of surgical residents: those who can only work shifts of
Surg Clin N Am 91 (2011) ix–xi doi:10.1016/j.suc.2011.07.002 surgical.theclinics.com 0039-6109/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
significantly less than one day and those who can follow patients clinically overnight. We now have PGY-1 residents who can no longer work more than 16 hours consecutively. Some may argue that we created a “shift-work” model in 2003 in response to the initial Institute of Medicine report “To Err is Human.” To be fair, some changes were proposed then but, if we are honest, many programs have still not fully implemented them and others have blurred many lines. One inescapable tidbit is that all the changes that were made in the stated guidelines for residency education conditions in 2003 were aimed at all resident levels and not just one subset. These new rules to be implemented this month create a class of learner (in our current parlance) that is not really a medical student and not really a resident. Perhaps we have lengthened medical school? Hard to argue that successfully since degrees have already been conferred prior to the learner arriving at the residency program and, furthermore, residency programs are completely regulated by the ACGME (Accreditation Council for Graduate Medical Education). The other characterization is that we have shortened residency. Many will argue that we haven’t done that because it still takes five years (minimum) to complete a general surgery residency. Personally, that argument seems specious to me as we absolutely lose time in training PGY 1 residents under conditions that would qualify one as a resident in all the other resident years that we never get back. That leaves the ultimate conclusion that more time and transition to increased responsibility has to be compressed into the last 4 years of general surgical residency. And since time is what time is—just ask Einstein—time cannot be compressed here on Earth and residency training is at least functionally shorter. So we have changed residency, at least in its first year, such that mandating time away from clinical experience is considered to be preferable to allowing continued observation for training superior surgeons. That is an interesting proposition. We should test it. But we won’t. If the above were true, we would expect a decrease in measurable complications. We might also expect an increase in some standardized test scores such as the American Board of Surgery (ABS) Qualifying Exam (QE) or the ABS Certifying Exam (CE). Perhaps we would get feedback from partners of newly graduated Chief Residents and Fellows that our newest additions to the nonsupervised work force were better prepared. While we cannot yet assess the new PGY-1 rules, we can look at the interval since the 2003 rules changed, to whatever degree they were implemented. One can look at the published results of the ABS and see that the pass rates for first-time CE candidates is falling somewhat dramatically. The QE first-time pass rates may be harder to interpret based on the nature of assigning a passing grade is already subjected to a curve. Feedback to the Fellowship of the American College of Surgeons through its Board of Governors has suggested that there is increasing concern among hirers of recent graduates that our newly “independent” surgeons are not as prepared to practice independently as their predecessors. And, at least in my institution, where I supervise a Morbidity and Mortality conference, we are seeing an increase in and a greater proportion of what we believe to be preventable errors as a result of handing off responsibility and ownership of a patient’s care between individuals. One caveat on this last bit is that it appears to be more attributable to handoffs between staff and faculty surgeons than resident surgeons. Still, it appears to us that failure of continuity is more dangerous than fatigue, although I cannot prove that at this time. I have not found good evidence that states we are producing better surgeons or getting better outcomes because of the changes, although it may be out there beyond my reach.
Many claims have been made along the way about the need for these changes; some of them wise and some of them not so wise. The least wise claim is the one that alleges that it is impossible to train competent surgeons under the “old” system. Unfortunately for proponents of that argument, we have nearly a century of surgical training and innovation that refutes that claim. Whether one likes or doesn’t like the method by which those people were trained, it is irrefutable that they were trained and much of what we know was discovered by them. Perhaps the wisest claim is, the old system, or its recent iterations, is not desirable, as it does not produce our best surgeons. That is an interesting hypothesis that we should be able to test. So back to gastric surgery: what Dr Fuhrman and his colleagues have done is given the reader a fresh look at a long-studied and thought to be well-understood area of surgery and medicine. Fresh looks are good. So good that we at Surgical Clinics always get a different guest editor when we revisit a topic. Through this fresh look we get a chance to see if our long-held assumptions still withstand scrutiny and if the current facts still support our beliefs. We surgeons should be encouraged by our history and should demand of our professional organizations, such as the American College of Surgeons, the American Board of Surgery, the Review Committee for Surgery, and the multitude of societies and other boards, that the proposed changes in training our future partners, and, perhaps as importantly, our own future surgeons (remember—everybody is preop, including us), should be designed and implemented with the expressed intent of testing these changes to see if they produce the desired goal. And if they don’t, we should modify the situation accordingly. There should be plans to assess whether these changes make the world a safer place for the patient or community by measurements that we can agree upon. There should be nodes in the decision plot that allow us to modify our trajectory of change, or even go back, if we find that our changes have made matters worse. And perhaps most importantly, we must be able to assess if a “best practice” model to train one specialty group of physicians is also the best for other specialties. We may find that a model that works best for pathologists is different than that for primary care or anesthesiologists or surgeons. In fact, I would be shocked if we didn’t. At present, these changes are made by fiat on questionable grounds largely about the impact of training schedules on the individual trainee and not about the impact of the future trainee on society. And at the end of the day, it is not about us—it is about the patient. We surgeons have historically prided ourselves on being leaders for the causes of our patients. Should we not do that now? Ronald F. Martin, MD Department of Surgery Marshfield Clinic 1000 North Oak Avenue Marshfield, WI 54449, USA E-mail address: [email protected]