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Presidential address: Routine complexity
Volume 130
Number 2
SURGERY AUGUST
2001
Society of University Surgeons Presidential address: Routine complexity Timothy R. Billiar, MD, Pittsburgh, Pa
From the Department of Surgery, Presbyterian Hospital, Pittsburgh, Pa
IT HAS INDEED BEEN an honor and a privilege to serve as president of the Society of University Surgeons (SUS), and I am humbled to stand before this esteemed body, which represents the best in academic surgery and, indeed, the professional world. I have immensely enjoyed the opportunity to work with so many outstanding individuals within the society and especially on the council. The title of this presidential address is “Routine complexity.” I use this term to introduce one of the major themes of my address: that the traditional missions of university surgeons have become seriously undervalued. Routine complexity refers to the routine completion of a very complex task. In other words, what each of us does on a day-to-day basis. I liken it to an accomplished artist who has toiled for years to express with clarity and ease an artistic vision. The Picasso creation Bull’s Head, which was heralded by critics as a masterpiece, is a good example. It took only minutes for the artist to create a painting out of a bicycle seat and handlebars, but it was the product of a lifetime of dedication toward the perfection of a very complex craft. Presented at the 62nd Annual Meeting of the Society of University Surgeons, Chicago, Ill, February 8-10, 2001. Reprint requests: Timothy R. Billiar, MD, George Vance Foster Professor and Chair, Department of Surgery, University of Pittsburgh, PO Box 7533, Pittsburgh, PA 15213. Surgery 2001;130:123-32. Copyright © 2001 by Mosby, Inc. 0039-6060/2001/$35.00 + 0 11/6/117979 doi:10.1067/msy.2001.117979
University surgeons also toil for years to perfect skills to complete complex tasks on a routine basis. Each of the many separate missions performed by university surgeons is complex, and the ability to balance these activities adds a level of difficulty not found with regularity in any other professional field. Changes over the past decade—including the decline of reimbursement, the near predatory stance from Health Care Financing Administration and the Office of the Inspector General targeting academic practices, the reductions in support for graduate medical education, and the threatened extinction of surgeon-scientists—have led many, both inside and outside the profession, to question the value of our nonclinical core missions. Perhaps more than any time in the history of academic surgery, the truly academic aspects of our mission stand threatened and without an effective voice. As time and departmental resources for educational and research activities dwindle, many ask, “How could this be? Why can’t government agencies and the public see the immense value of our efforts?” One answer is obvious. In the era of managed care, those who are now in positions to make key decisions affecting our profession simply do not understand or maybe do not want to acknowledge the importance of what we do. They may not have asked, but have we told them? Are we victims of our own success? Is what we do so complex that it would be foolish to assume that those outside of the profession should be expected to understand SURGERY 123
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Table I. University surgeon: Job training requirements 1. Bachelor’s degree in natural or physical sciences • Graduation in top 5% of class expected 2. MD degree from prestigious medical school • Graduation with honors in surgery expected 3. Completion of a general surgery residency in a university program • Master patient management and operative techniques in GI surgery, trauma surgery, vascular surgery, endocrine surgery, oncologic surgery, and critical care • Time commitment of 5 years, 80 to 100 hours per week 4. Clinical fellowship training (optional but often required) • Time requirement: 1 to 3 years, 80 to 100 hours per week 5. Research fellowship • Become an expert in an area of clinical or basic science • Demonstrate proficiency in hypothesis development, experimental design, presentation, and writing skills by giving numerous national talks and publishing peer-reviewed papers (PhD helpful but not required) • Time requirement: 1 to 4 years
not only the importance of our contributions, but the dedication and excellence needed to succeed? I will address 3 areas relevant to these questions. First, how do we define the value of what we do? Second, what are the factors that have led to our current state? Third, what is the importance of advocacy in affecting future trends? TRAINING AND JOB DESCRIPTION FOR UNIVERSITY SURGEONS One risk of the negative reinforcement academic surgeons have experienced in recent years is disenfranchisement—a failure of many of the participants to appreciate their own worth. If we do not differentiate our mission from that of other medical professionals, we cannot expect society or government agencies to do the same. In thinking about this, it struck me that even though I had dedicated almost 2 decades to prepare for my professional career, I had never seen a job description for what it is that we do. The concept of describing our profession in such lay terms may seem absurd. However, for the public and administrative bodies to understand the value of what we do, what we do needs to placed in context. Therefore, allow me to propose training requirements and a job description for university surgeons (Table I). University surgeons are required to obtain a bachelor’s degree and graduate typically in the top 5% of the class. This is necessary if you want to be competitive and pursue an MD degree from a prestigious medical school. If you cannot afford to pay for this formal education, that is all right, but plan on graduating with a debt that in 2001 has grown to about $100,000 with no deferment during the subsequent training period.
Medical school must be followed by a surgical residency, where a wide range of cognitive and technical skills must be mastered in 5 years of 80 hours of training per week. Clinical fellowships add another 1 to 3 years of specialty training. Research experience and success are mandatory. Not only is a fellowship required, but the candidate must become an expert in an area of clinical or basic science and demonstrate proficiency in all the skills required to conduct the successful research program. The time requirement ranges from 1 to 4 years. On average, this education takes 16 to 18 years, and the typical age upon completion is somewhere in the mid-30s. In my own household, the average education and training period was 17 1⁄2 years. This extensive training period then serves as the basis for completing the different tasks in the job description of the typical university surgeon (Table II). I do not intend to be disrespectful, but I will use the term employee, because many of us now work for corporations that are part of larger health systems. An employee in this field of work is expected to be a role-model clinician, delivering the most advanced lifesaving surgical care to the most complicated patients, and as a role model, an employee possesses all of the attributes listed in Table II. Teaching is also part of the job description, and the employee is expected to design and implement a program that teaches the art of surgery, including basic and advanced skills, to both surgeons and non-surgeons. By definition, university surgeons carry out biomedical research. This research should be novel, whether basic or clinical, and there should be clear evidence of success by established criteria of publications, grants, patents, peer-review activities, and
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Table II. University surgeon: Job description 1. Clinical skills • Employee expected to be a role model clinician in delivering the most advanced, life-saving surgical care to the most complicated patients • Outstanding preoperative and postoperative management • Excellent technical skills • Superior judgment • Clinical leadership • Assume inherent risk 2. Teaching skills • Employee expected to design and implement program to teach the art of surgery to both nonsurgeon and surgeon trainees, including basic and advanced skills • Requires advanced teaching skills both in the classroom and on the job 3. Biomedical research • Employee expected to conduct novel basic or clinical research with evidence of success based on: • Regular publications in peer-reviewed journals • Successful grant applications • Successful patent applications • Participate locally and nationally in peer-review process • Understand and comply with complex regulations 4. Mentoring • Employee expected to provide mentoring to students, residents, fellow, and junior faculty • Council students on career choices • Monitor progress of surgical trainees • Mentor students and fellows through research training • Mentor surgical trainees and junior faculty to become successful academic surgeons 5. Administrative activities • Employee expected to progressively increase administrative activities in the department, medical school, and health system without a reduction in other responsibilities • Understand and implement institutional and governmental policies • Understand health care and research finances 6. Promote academic surgery worldwide • Employee expected to become active in national and international surgical and scientific societies • Requires 8 to 10 weeks of travel per year
academic promotion. The employee is expected to serve as mentor to students, residents, and fellows, as well as to junior faculty. This role requires significant counseling skills and mentoring in both the clinical and the research arena. All university surgeons eventually participate in administrative activities in the department, medical school, and health system, typically without a reduction in other responsibilities. And finally, a university surgeon is expected to promote surgery worldwide and become active in national and international surgical and scientific societies, traveling typically 8 to 10 weeks per year. I have described several separate tasks, each requiring a unique set of skills. The university surgeon is expected to perform these tasks simultaneously; hence, the need for broad and protracted training. But through this broad training, the university surgeon is uniquely prepared to serve as the link between the research bench and the bedside, and the patient and the
educational mission. I would challenge anyone to provide an example of a qualified profession that requires a greater diversity of skill, motivation, and talent than the university surgeon. With job description in hand, I then sought a tool to assess the value of our profession based on society standards. I learned that there is no straightforward metric to estimate the value of our professional activities. The Bureau of Labor Statistics attempts to define the value of a profession by assigning something known as “work level.” Work level is calculated from the 9 different job factor categories and includes skills such as knowledge and complexity. Based on how a profession is rated within each category, work levels may range from 1 as the lowest, to 15 as the highest. Surgeons are not addressed separately in this evaluation; however, physicians are. It will not come as a surprise to you that the job description of a university surgeon places our profession at the very highest work level.
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Table III. Contributions of surgical research: The last 50 years • Cardiopulmonary bypass • Transplantation • Vascular surgery • Total parenteral nutrition • Metabolic response to sepsis and trauma: burn care • Controlled clinical trials for cancer (breast) • Effects of hormones on cancer • Minimally invasive surgery Adapted from Thompson JC. Gifts from surgical research. Contributions to patients and to surgeons. J Am Coll Surg 2000;190:391-403.
Table IV. Medicare fee schedule Procedure Central line Excision breast lesion Laporotomy Tracheostomy
2000
2001
Change
126.04* 369.00 680.64 240.93
147.23 408.35 707.61 227.98
+21.19 +39.35 +26.97 –12.95
*Payment per procedure in dollars.
If you look at the category of required knowledge, university surgeon is at the highest level for demonstrating a mastery of the professional field to develop new hypotheses. I would take you through 9 categories, but all that exercise would confirm what we all know: that even in the view of those who try to assign value to professional endeavors, there is no attempt to differentiate between academic and nonacademic physicians, let alone university surgeons from physician groups, with a much more narrow range of occupational objectives. Most surgeons in this room would probably agree that the value of university surgeons might be better portrayed by the contributions of university surgeons to public health. James Thompson eloquently described the major accomplishments of academic surgery over the past 50 years in his presidential address before the American College of Surgeons, in which he highlighted cardiac surgery, transplantation, and controlled clinical trials for cancer, among several others (Table III).1 It is impossible to place a societal value on these accomplishments, but of course none would have occurred without the efforts of university surgeons eager to fulfill their job descriptions. No direct measure to gauge public perception of the value of university surgeons is available. Public perception of physicians as a whole is regularly assessed, and the information here is positive. For example, a 2000 Gallup Poll ranked medical doctors fourth in terms of honesty and ethics, with 63% of responders indicating that physicians
exhibit either “high” or “very high” ethics. Doctors of medicine were actually ranked ahead of grade school teachers and the clergy. Not suprisingly, other professions did not fare quite as well. For example, legislators received only a 24% positive vote, lawyers 17%, and, in 1999, HMO managers ranked just below gun salesmen and slightly above telemarketers. Also impressive is the increase in the public’s perception of the integrity of the medical profession over the past 20 years, which has steadily increased. Assuming that this positive public image can be extended to university surgeons, it is reasonable to conclude that at least our public image would be quite positive if we just told society what it is that we do. Another metric to estimate the perceived value of our efforts is compensation. Data from the American Association of Medical Colleges (AAMC) from 1999 indicate that general surgeons in academic practice have average annual salaries, which range from $179,000 for assistant professor to $263,000 for full professor.2 These are certainly respectable numbers, but it should not go unnoticed that, if anything, average values have dropped slightly in the past year. Furthermore, based on the training and job description, these levels of compensation cannot be considered extravagant relative to scale within our society. An even more important number not revealed in the compensation values is the revenue needed to meet these salaries. For example, in our institution, $426,000 of annual revenue is needed to meet
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Fig 1. Medical schools and the academic mission
a salary of $179,000, and this number increases to $626,000 to cover the salary of a full professor. As academic practice has grown dependent on clinical revenues, payers have not differentiated between private and academic practice. A quick review of the Medicare fee schedule3 for some of the more common surgical procedures immediately reveals the challenge (Table IV). Even with the trivial increase for some procedures in the past year, fees for clinical services remain so low that a private practice mentality dominates the academic center. 80-hour work weeks combining clinical work with research and/or education have been replaced by 80 hours of pure clinical effort. It is essential that I state that the issue is not personal compensation but failure to secure alternative sources of support for the academic mission during this period of declining clinical revenues. Compensation levels remain an issue only in that adequate compensation is required to attract and retain the exceptional talent needed to carry out our complex job description. The real irony in the changes that have occurred over the past decade is that not only have the academic opportunities for university surgeons diminished, but due to higher overheads in many academic programs, university surgeons are forced to generate more clinical revenue than even their private practice counterparts in order to secure a lower level of compensation. Lest I be accused of delivering an entirely negative message, I should point out that some relief is in sight. Medicare payment rates appear to have stabilized, and the National Institutes of Health’s (NIH) budget continues to grow. A significant increase in
the NIH salary cap to $161,200 offers university surgeons, for the first time at least, the possibility of securing enough salary support from NIH grants to adequately cover expenses. But have the research infrastructure and academic pipeline been so wounded that they cannot recover? More important, have the unique needs of surgeons in terms of training duration, time demands, and clinical areas of importance really been addressed? When will the value of educational mission be recognized? Before I consider, in the next section of my talk, some of the factors that have contributed to the current state, I want to emphasize a very important point. We are still in a relatively young field that, in truth, has known nothing but rapid change. The university surgeon who bemoans the rapid changes we now face fails to appreciate the pace of change in our profession. Just consider the state of surgery 100 years ago. Ether anesthesia had been identified only a few decades earlier, the American Surgical Association had just formed, and the first Halsteadtype residency had been established at Johns Hopkins. The American College of Surgeons, the American Board, and the SUS did not exist, and all of what would become the great accomplishments of the 20th century were considered out of reach. Operating theaters bore minimal resemblance to the high-tech facilities of today. The lesson is clear: change is constant and must be embraced. But not all change has been positive, and both society and academic physicians, including surgeons, must take responsibility for the current state of academic medicine. The noted medical historian Keith Ludmerer perhaps states the second point of this address best in his
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Table V. The university surgeon as advocate • Be a builder—have a programmatic focus • Align your objectives with the department and medical center • Seek appropriate rewards • Use all available portals for advocacy • Take others with you
recent book Time to Heal–American Medical Education from the Turn of the Century to the Era of Managed Care. Concerning the past decade, he writes: As the millennium approached, the learning environment in academic health centers was eroding, faculty research was decreasing and faculty incomes depended mainly on the private practice of medicine rather than on teaching and research. The social contract between society and medical education had been broken. Society was no longer providing academic health centers with sufficient financial or political support. In turn, medical faculties had grown inwardly focused.4
His conclusions are clear. The great successes in academic medicine of the 20th century were a consequence of a partnership between society and medical schools. The loss of this connection contributed to a loss of public support for our mission, and instead of rebuilding a support base, the academic physician has grown ever more insular, circling the wagons to protect resources as autonomy vanished and incomes became threatened. THE FORCES OF CHANGE There have been many forces, most of them financial, that led to the academic crisis of the 1990s. Understanding these forces and the rapid pace of change in academic medicine is critical to charting an effective course for the future (Fig 1). At least some of the origins extend back to the late 1800s, when many of the medical schools in the United States were proprietary, in that they were private, for-profit schools that paid little attention to admission criteria and gave no direct exposure to patient care. The deplorable state of medical education in the United States at the turn of the century was detailed in 1910 in the famous Flexner Report, which called for sweeping changes.5 Using the recently established Johns Hopkins School of Medicine as an example, Abraham Flexner proposed that patient care, education, and research should be part of university-based programs and serve as the foundation of medical education. This report had dramatic effects often referred to as the first revolution in US medical education. Understanding the potential benefit to the public
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health, society embraced the mission outlined by the report and provided the support for universities and medical schools through government spending and philanthropy. A number of outstanding medical schools originated in this period as proprietary schools vanished. Education became the dominant theme within these university-based schools. Patients benefitted, because hands-on patient care became part of the teaching method. As the quality of doctors improved, a powerful bond developed between the public and medical schools. The Flexner report had also clearly identified the importance of research to the advancement of the academic mission, and with the increased governmental and public support, medical schools had become fully invested in the research enterprise. By the time the NIH was established in 1930, the United States had become the world’s leader in biomedical research. The bond between society and medical schools remained strong as one amazing discovery after another emanated from the great universities of this country. The NIH budget started to grow exponentially and between 1930 and 1966 was the financial force behind the academic missions. Society supported the mission of academic health systems, and faculties clearly understood that implicit within their position was a major element of public service. Although research had become a dominant theme in the 1940s and 1950s, the commitment to education remained strong. Both the good news and the bad news was that the decades of investment in research paid off. Through advancements in technology, patients with chronic disease began to live longer, and new effective, but expensive, therapies became commonplace. In the 1960s, Medicare and Medicaid began to pay rising costs, which introduced the most powerful financial force yet—clinical revenues. Medical schools responded by increasing faculty sizes, as well as clinical volume, to take advantage of this new source of revenue. Patient care, as a clinical service, as opposed to a vehicle for the educational mission, became the dominant theme. Annual medical spending in the United States increased rapidly. Starting at $27 billion per year in 1960, spending has nearly tripled in every decade since. Medical expenditures as part of the gross national product increased from under 5% to nearly 15% in this period. The change was also seen in mean faculty salaries. Ranging from $18,000 to $28,000 per year in the 1960s, surgeon salaries grew tenfold, to the current levels6—a growth beyond what can be explained simply by inflation.
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As health care costs grew, physicians were chided for their inability or unwillingness to control patient care costs. This led to the introduction of managed care, starting in the early 1980s with the institution of diagnosis-related groups, which did not fully take hold until the early 1990s. This rapid introduction of managed care has been referred to by some as the second revolution in American medical education. A second and extremely important consequence of the change in the focus of US medical schools from education and research to clinical care has been a clear disruption in the social bond between medical schools and the public. In the era of plenty, faculties grew aloof, and as the reins tightened, all sectors of the medical community attempted to build firewalls to protect their shrinking sources of revenue. THE NEED FOR ADVOCACY With these thoughts in mind, the final and most important message I would like to deliver is that now, more than ever, the success of our mission as university surgeons requires advocacy to rebuild our bond with society. By advocacy, I mean reaching out to educate individuals, groups, and organizations about the importance of our mission. There are many compelling reasons for an aggressive advocacy campaign. Society must be continuously reminded that what we do is extremely important. The evidence is written in the stories of millions of lives that have been positively impacted through the contributions of university-based surgeons. Major advances have followed years of struggle and have come only through the perseverance of a small community of dedicated academic surgeons. Our mission is indeed costly and requires access to resources that are growing ever more scarce in an environment in which there are many competing interests. Change is constant and rapid, and a failure to act leaves our fate to the growing administrative hierarchies that increasingly control resources. We need strong advocacy, because we represent a minority even within the profession of surgery. Based on the rosters of the SUS, university surgeons account for only 3% of surgeons practicing in general surgery and the specialties relevant to our Society. Who will act as advocate for the university surgeon and his or her mission? I propose that there are 3 major forces for change—the individual surgeon, academic departments, and societies, such as the SUS. All these groups must understand that there are numerous portals for advocacy, and we are presented with opportunities almost daily, start-
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Table VI. The academic department as advocate 1. Department leadership must define the missions 2. Department missions must have value to the public: • Excellent clinical programs • Education • Clinically relevant research 2. Publicize the mission: use information technology 3. Set the standards for patient care • Outcomes research 4. Create a positive environment for students and residents 5. Advocate for the academic mission within the system
ing with patients and their families, and extending to payers, students, and even the governmental bodies that regulate our lives. All the constituents of our professional lives must be continuously educated on the value of the academic mission. Advocacy must start with the individual surgeon (Table V). The first step is to be a builder. By a builder I mean someone who develops something of unique value, whether that be a successful research program or a busy clinical practice with programmatic focus. Increase your value by aligning your objectives with the overall goals of the department and medical center. Only by having a position of value and authority within your own environment can you have a voice that is heard. As you build successful programs around yourself, it is important to continue to seek appropriate rewards. Simply translating your success into higher personal income sends the wrong message and will not benefit the overall academic mission, and it may not even provide long-term security. Competitive compensation levels coupled with other rewards, such as accelerated academic promotion and greater authority within your environment, will have lasting impact. Use all of the available portals, again starting with patients. Use the patient as advocate, and at the same time, be the champion of patient issues. Do not forget to take others with you in this process. Remember, you are a role model and take pride in generating enthusiasm for the opportunities in academic surgery. To paraphrase my mentor, Richard Simmons, the best way to receive credit and enhance your own standing is to give credit to others. To be insular in this era, even in your own environment, is academic and professional suicide. Academic departments are also in a position to serve as advocates (Table VI). Advocacy at the department level must start with the leadership clearly defining department priorities and objectives that have obvious value to the public and
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Table VII. SUS as advocate: opportunities • Active participation in more influential academic organizations: AAMC, ABS, ACS • Public information campaign • Lobby governmental agencies • Form policy consortium with other academic surgical societies
include the traditional missions of exceptional clinical programs, education, and clinically relevant research. Information technologies should be used to publicize departmental programs. Academic departments working alone or in consortiums need to place even greater emphasis on the importance of outcomes research. Not only patients, but also patient advocacy groups and payers understand the importance of optimizing therapies—setting the standards of care within your own health care system and the country, in a sense. An example of the importance of this type of advocacy was seen recently in a statement released by the Leapfrog Group, a consortium of Fortune 500 companies that provides health care benefits to some 20 million Americans and spends nearly $40 billion dollars a year on health care.7 With the goal of reducing medical errors, this panel defined criteria for providers that contracted for health care dollars in their companies. Recommendations included computerized physician order entry, evidence-based hospital referral, and 24-hour intensive care unit staffing by critical care specialists. We have used the Leapfrog report as an argument to enhance the intensive care unit coverage in some of our hospitals. Evidence-based research can have a great impact on payers if we have the support of powerful groups such as these. Education must remain on the forefront of the departmental mission. This includes not only educating medical students but also the next generation of surgeons. Departments must develop innovative methods for training surgeons outside of the operating room to dispel the concerns within society that resident surgeons practice their operative skills on patients. At the University of Pittsburgh, like many institutions, we are building an education center for the instruction in basic and minimally invasive surgical techniques. We have launched a publicity campaign to raise the awareness of the public to our training mission and to generate revenue to support the center, not only from the public but also industry and our own health care system. This center bears the name of the late Charles Watson, a great surgeon educator in our department. Within departments, an emphasis must be placed on creating an environment with positive role mod-
els, while remembering that our words and actions will profoundly influence the decisions our students make. The department leadership and the entire department must also act as advocate for the academic mission within the regional system. Health system administrators must be made to understand the importance of academic success within the department to the system. The relationship is clear: “academic success attracts new talent and talented university surgeons bring the motivation, skills, and ingenuity needed to build effective programs.” Finally, our academic surgical societies have not been adequately exploited for an advocacy role (Table VII). One may ask why the SUS should act as advocate when so many other advocacy groups for physicians and surgeons exist. The answers are clear. Among surgeons, university surgeons are a minority. Other more general academic medical organizations have not addressed the unique needs of the university surgeon. Just consider the issue of NIH peer review and the ongoing struggle to assure surgeon and scientist representation within the NIH peer-review process. And finally, only the SUS, along with the American Surgical Association and the Association for Academic Surgery, truly represent the university-based surgeon. Like most academic societies, the SUS has focused its attention inward within recent years. Last year, President Beauchamp spoke of the need for academic surgeons to evolve in a complex environment.8 Two years ago, President Cioffi called for leadership and mentorship in these challenging times.9 These timely and important messages spoke of the importance of change within ourselves to provide the leadership essential to ensure our continued success as university surgeons and as a Society. As we heed these important messages, it is now time to expand our efforts outside of the Society and to use the SUS as a powerful tool for advocacy. Thanks to visionary leadership, changes have been made in recent years that position the SUS to become a more effective advocate. Active membership has been extended to age 50, which permits greater individual participation in advocacy efforts. The annual meeting has been enhanced to better meet the needs of the members and permit a greater mentoring role by including the residents’
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program in the main meeting. The recent institution of an annual 2-day strategic planning meeting and a proposal to form a separate membership committee are moves that permit the council to invest more time on other issues, such as advocacy. There are multiple potential avenues for the SUS to act as advocate. The most straightforward is active participation in the more influential national organizations, such as the AAMC, the American Board of Surgery (ABS), and the American College of Surgeons (ACS). These national organizations have greater resources at their disposal. The AAMC is the national advocacy group for the academic mission. However, academic surgeons have had a limited voice within the AAMC. Dr George Sheldon, SUS member and head of the Council of Academic Societies, presents the SUS with a golden opportunity to become more influential within the AAMC. Toward this end, the SUS council has proposed a number of significant changes in our interaction with the AAMC, as well as with the ACS and the ABS. The SUS sends 2 representatives to each of these organizations. In recent years, these representatives have served primarily as a one-way conduit, providing information back to the SUS on ongoing activities in these other organizations. In a concerted effort to promote two-way communication, the council has extended the involvement of these representatives. Now, one each will participate as members of either the Committee on Social and Legislative Issues or in the Committee on Education. In the future, these SUS representatives will bring to the appropriate committees and the council issues on the forefront within the AAMC, the ABS, or the ACS for consideration. The committee will then prepare position statements. The proposed sequence of events is as follows. During the February council meeting, the council will identify the key issues for consideration by the committees. In the intervening time, the committee members, including the representatives, will draft position statements that will be brought forth during the June planning meeting. The drafts will be appropriately modified during the planning session and then distributed to the membership during the summer for feedback. During the October council meeting, the final statements will be approved by council, and the representatives will convey the SUS position to the appropriate body and seek feedback. This first small but significant step toward SUS advocacy represents a significant departure from business as usual. However, the seeds for this movement were planted by Bill Cioffi 2 years ago, and it
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is not too different from the proposal made in 1984 by a past president, Bernard Jaffe, during his presidential address.10 His call for advocacy was followed by a similar suggestion for greater participation of the SUS representatives. In order for this approach to be effective, the council and future leaders of the SUS will need to support and promote these changes. Other opportunities for SUS advocacy should also be considered. The SUS could use its Web site as an information resource about university surgeons to be used by individual surgeons, departments, and other societies. Consideration should also be given to a lobbying effort. Combining resources with other like-minded societies, such as the ASA or the AAS, through the formation of policy consortiums would add the weight of both numbers and influential surgeons to an advocacy effort. There are several themes important to the academic mission that future SUS leadership should consider addressing as part of an ongoing advocacy effort. Topics include greater surgeon and scientist representation in NIH peer-review processes, more support for surgical education, and loan-forgiveness programs that take into consideration the unique needs of young surgeons and scientists. Finally, the Society should advocate for greater NIH support for outcomes research. Effective advocacy will require that we learn a new way of thinking—a departure from the traditional insular behavior of academic surgeons and a move toward self-promotion. The only thing that is certain is that change is constant. The failure to adequately react in the past must be placed behind us. History should teach us that unless we are willing to step forward and actively participate on a national level in our own destiny, our destiny will be determined by short-sighted individuals more concerned with immediate financial bottom line than the long-term impact of their decisions. I state again, this cannot be about personal compensation; it must be about the resources and the support needed to complete a complex mission, a mission that only a relative few highly motivated, dedicated, and exceptionally talented individuals can achieve. If we have not learned anything else in recent years, we must understand now that we cannot achieve this mission without the support of the public. The last decade has been most challenging for academic surgery. However, the new millennium presents new opportunities to those willing to actively participate in their own destiny. Therefore, I conclude by urging each member, departmental leader, and leader of this Society, to become an
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active advocate for the academic mission of university surgeons. In closing, let me again express my gratitude to the membership for the honor of serving as president of this esteemed Society. REFERENCES 1. Thompson JC. Presidential address: gifts from surgical research. Contributions to patients and to surgeons. Clinical Congress of the American College of Surgeons. American College of Surgeons 2000. p. 391-403. 2. AAMC Publications and Information Resources: AAMC Data Book. 2000. 3. Medicare Special Bulletin. November 17, 2000. 4. Ludmerer KM. Introduction. In: Time to heal, American medical education from the turn of the century to the era of managed care. New York: Oxford University Press; 1999. p. 25.
5. Flexner A. Medical education in the United States and Canada. New York: Carnegie Foundation for the Advancement of Teaching; 1910. 6. Ludmerer KM. Faculty salaries, 1965. In: Time to heal, American medical education from the turn of the century to the era of managed care. New York: Oxford University Press; 1999. p. 155. 7. Birkmeyer JD, Birkmeyer CM, Wennberg DE, Young M. Leapfrog Patient Safety Standards: the potential benefit of universal adoption. The Leapfrog Group for Patient Safety Rewarding Higher Standards. Sponsored by the Business Roundtable. November 2000. 8. Cioffi WG. Presidential address: SUS mentorship in Y2K–passion, leadership, perspective. Surgery 1999;126:10111. 9. Beauchamp RD. Presidential address: evolution. Surgery 2000;128:123-32. 10. Jaffe BM. Presidential address: how big the bite? Surgery 1984;96:129-32.
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Number 2
SURGERY AUGUST
2001
Society of University Surgeons Presidential address: Routine complexity Timothy R. Billiar, MD, Pittsburgh, Pa
From the Department of Surgery, Presbyterian Hospital, Pittsburgh, Pa
IT HAS INDEED BEEN an honor and a privilege to serve as president of the Society of University Surgeons (SUS), and I am humbled to stand before this esteemed body, which represents the best in academic surgery and, indeed, the professional world. I have immensely enjoyed the opportunity to work with so many outstanding individuals within the society and especially on the council. The title of this presidential address is “Routine complexity.” I use this term to introduce one of the major themes of my address: that the traditional missions of university surgeons have become seriously undervalued. Routine complexity refers to the routine completion of a very complex task. In other words, what each of us does on a day-to-day basis. I liken it to an accomplished artist who has toiled for years to express with clarity and ease an artistic vision. The Picasso creation Bull’s Head, which was heralded by critics as a masterpiece, is a good example. It took only minutes for the artist to create a painting out of a bicycle seat and handlebars, but it was the product of a lifetime of dedication toward the perfection of a very complex craft. Presented at the 62nd Annual Meeting of the Society of University Surgeons, Chicago, Ill, February 8-10, 2001. Reprint requests: Timothy R. Billiar, MD, George Vance Foster Professor and Chair, Department of Surgery, University of Pittsburgh, PO Box 7533, Pittsburgh, PA 15213. Surgery 2001;130:123-32. Copyright © 2001 by Mosby, Inc. 0039-6060/2001/$35.00 + 0 11/6/117979 doi:10.1067/msy.2001.117979
University surgeons also toil for years to perfect skills to complete complex tasks on a routine basis. Each of the many separate missions performed by university surgeons is complex, and the ability to balance these activities adds a level of difficulty not found with regularity in any other professional field. Changes over the past decade—including the decline of reimbursement, the near predatory stance from Health Care Financing Administration and the Office of the Inspector General targeting academic practices, the reductions in support for graduate medical education, and the threatened extinction of surgeon-scientists—have led many, both inside and outside the profession, to question the value of our nonclinical core missions. Perhaps more than any time in the history of academic surgery, the truly academic aspects of our mission stand threatened and without an effective voice. As time and departmental resources for educational and research activities dwindle, many ask, “How could this be? Why can’t government agencies and the public see the immense value of our efforts?” One answer is obvious. In the era of managed care, those who are now in positions to make key decisions affecting our profession simply do not understand or maybe do not want to acknowledge the importance of what we do. They may not have asked, but have we told them? Are we victims of our own success? Is what we do so complex that it would be foolish to assume that those outside of the profession should be expected to understand SURGERY 123
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Table I. University surgeon: Job training requirements 1. Bachelor’s degree in natural or physical sciences • Graduation in top 5% of class expected 2. MD degree from prestigious medical school • Graduation with honors in surgery expected 3. Completion of a general surgery residency in a university program • Master patient management and operative techniques in GI surgery, trauma surgery, vascular surgery, endocrine surgery, oncologic surgery, and critical care • Time commitment of 5 years, 80 to 100 hours per week 4. Clinical fellowship training (optional but often required) • Time requirement: 1 to 3 years, 80 to 100 hours per week 5. Research fellowship • Become an expert in an area of clinical or basic science • Demonstrate proficiency in hypothesis development, experimental design, presentation, and writing skills by giving numerous national talks and publishing peer-reviewed papers (PhD helpful but not required) • Time requirement: 1 to 4 years
not only the importance of our contributions, but the dedication and excellence needed to succeed? I will address 3 areas relevant to these questions. First, how do we define the value of what we do? Second, what are the factors that have led to our current state? Third, what is the importance of advocacy in affecting future trends? TRAINING AND JOB DESCRIPTION FOR UNIVERSITY SURGEONS One risk of the negative reinforcement academic surgeons have experienced in recent years is disenfranchisement—a failure of many of the participants to appreciate their own worth. If we do not differentiate our mission from that of other medical professionals, we cannot expect society or government agencies to do the same. In thinking about this, it struck me that even though I had dedicated almost 2 decades to prepare for my professional career, I had never seen a job description for what it is that we do. The concept of describing our profession in such lay terms may seem absurd. However, for the public and administrative bodies to understand the value of what we do, what we do needs to placed in context. Therefore, allow me to propose training requirements and a job description for university surgeons (Table I). University surgeons are required to obtain a bachelor’s degree and graduate typically in the top 5% of the class. This is necessary if you want to be competitive and pursue an MD degree from a prestigious medical school. If you cannot afford to pay for this formal education, that is all right, but plan on graduating with a debt that in 2001 has grown to about $100,000 with no deferment during the subsequent training period.
Medical school must be followed by a surgical residency, where a wide range of cognitive and technical skills must be mastered in 5 years of 80 hours of training per week. Clinical fellowships add another 1 to 3 years of specialty training. Research experience and success are mandatory. Not only is a fellowship required, but the candidate must become an expert in an area of clinical or basic science and demonstrate proficiency in all the skills required to conduct the successful research program. The time requirement ranges from 1 to 4 years. On average, this education takes 16 to 18 years, and the typical age upon completion is somewhere in the mid-30s. In my own household, the average education and training period was 17 1⁄2 years. This extensive training period then serves as the basis for completing the different tasks in the job description of the typical university surgeon (Table II). I do not intend to be disrespectful, but I will use the term employee, because many of us now work for corporations that are part of larger health systems. An employee in this field of work is expected to be a role-model clinician, delivering the most advanced lifesaving surgical care to the most complicated patients, and as a role model, an employee possesses all of the attributes listed in Table II. Teaching is also part of the job description, and the employee is expected to design and implement a program that teaches the art of surgery, including basic and advanced skills, to both surgeons and non-surgeons. By definition, university surgeons carry out biomedical research. This research should be novel, whether basic or clinical, and there should be clear evidence of success by established criteria of publications, grants, patents, peer-review activities, and
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Table II. University surgeon: Job description 1. Clinical skills • Employee expected to be a role model clinician in delivering the most advanced, life-saving surgical care to the most complicated patients • Outstanding preoperative and postoperative management • Excellent technical skills • Superior judgment • Clinical leadership • Assume inherent risk 2. Teaching skills • Employee expected to design and implement program to teach the art of surgery to both nonsurgeon and surgeon trainees, including basic and advanced skills • Requires advanced teaching skills both in the classroom and on the job 3. Biomedical research • Employee expected to conduct novel basic or clinical research with evidence of success based on: • Regular publications in peer-reviewed journals • Successful grant applications • Successful patent applications • Participate locally and nationally in peer-review process • Understand and comply with complex regulations 4. Mentoring • Employee expected to provide mentoring to students, residents, fellow, and junior faculty • Council students on career choices • Monitor progress of surgical trainees • Mentor students and fellows through research training • Mentor surgical trainees and junior faculty to become successful academic surgeons 5. Administrative activities • Employee expected to progressively increase administrative activities in the department, medical school, and health system without a reduction in other responsibilities • Understand and implement institutional and governmental policies • Understand health care and research finances 6. Promote academic surgery worldwide • Employee expected to become active in national and international surgical and scientific societies • Requires 8 to 10 weeks of travel per year
academic promotion. The employee is expected to serve as mentor to students, residents, and fellows, as well as to junior faculty. This role requires significant counseling skills and mentoring in both the clinical and the research arena. All university surgeons eventually participate in administrative activities in the department, medical school, and health system, typically without a reduction in other responsibilities. And finally, a university surgeon is expected to promote surgery worldwide and become active in national and international surgical and scientific societies, traveling typically 8 to 10 weeks per year. I have described several separate tasks, each requiring a unique set of skills. The university surgeon is expected to perform these tasks simultaneously; hence, the need for broad and protracted training. But through this broad training, the university surgeon is uniquely prepared to serve as the link between the research bench and the bedside, and the patient and the
educational mission. I would challenge anyone to provide an example of a qualified profession that requires a greater diversity of skill, motivation, and talent than the university surgeon. With job description in hand, I then sought a tool to assess the value of our profession based on society standards. I learned that there is no straightforward metric to estimate the value of our professional activities. The Bureau of Labor Statistics attempts to define the value of a profession by assigning something known as “work level.” Work level is calculated from the 9 different job factor categories and includes skills such as knowledge and complexity. Based on how a profession is rated within each category, work levels may range from 1 as the lowest, to 15 as the highest. Surgeons are not addressed separately in this evaluation; however, physicians are. It will not come as a surprise to you that the job description of a university surgeon places our profession at the very highest work level.
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Table III. Contributions of surgical research: The last 50 years • Cardiopulmonary bypass • Transplantation • Vascular surgery • Total parenteral nutrition • Metabolic response to sepsis and trauma: burn care • Controlled clinical trials for cancer (breast) • Effects of hormones on cancer • Minimally invasive surgery Adapted from Thompson JC. Gifts from surgical research. Contributions to patients and to surgeons. J Am Coll Surg 2000;190:391-403.
Table IV. Medicare fee schedule Procedure Central line Excision breast lesion Laporotomy Tracheostomy
2000
2001
Change
126.04* 369.00 680.64 240.93
147.23 408.35 707.61 227.98
+21.19 +39.35 +26.97 –12.95
*Payment per procedure in dollars.
If you look at the category of required knowledge, university surgeon is at the highest level for demonstrating a mastery of the professional field to develop new hypotheses. I would take you through 9 categories, but all that exercise would confirm what we all know: that even in the view of those who try to assign value to professional endeavors, there is no attempt to differentiate between academic and nonacademic physicians, let alone university surgeons from physician groups, with a much more narrow range of occupational objectives. Most surgeons in this room would probably agree that the value of university surgeons might be better portrayed by the contributions of university surgeons to public health. James Thompson eloquently described the major accomplishments of academic surgery over the past 50 years in his presidential address before the American College of Surgeons, in which he highlighted cardiac surgery, transplantation, and controlled clinical trials for cancer, among several others (Table III).1 It is impossible to place a societal value on these accomplishments, but of course none would have occurred without the efforts of university surgeons eager to fulfill their job descriptions. No direct measure to gauge public perception of the value of university surgeons is available. Public perception of physicians as a whole is regularly assessed, and the information here is positive. For example, a 2000 Gallup Poll ranked medical doctors fourth in terms of honesty and ethics, with 63% of responders indicating that physicians
exhibit either “high” or “very high” ethics. Doctors of medicine were actually ranked ahead of grade school teachers and the clergy. Not suprisingly, other professions did not fare quite as well. For example, legislators received only a 24% positive vote, lawyers 17%, and, in 1999, HMO managers ranked just below gun salesmen and slightly above telemarketers. Also impressive is the increase in the public’s perception of the integrity of the medical profession over the past 20 years, which has steadily increased. Assuming that this positive public image can be extended to university surgeons, it is reasonable to conclude that at least our public image would be quite positive if we just told society what it is that we do. Another metric to estimate the perceived value of our efforts is compensation. Data from the American Association of Medical Colleges (AAMC) from 1999 indicate that general surgeons in academic practice have average annual salaries, which range from $179,000 for assistant professor to $263,000 for full professor.2 These are certainly respectable numbers, but it should not go unnoticed that, if anything, average values have dropped slightly in the past year. Furthermore, based on the training and job description, these levels of compensation cannot be considered extravagant relative to scale within our society. An even more important number not revealed in the compensation values is the revenue needed to meet these salaries. For example, in our institution, $426,000 of annual revenue is needed to meet
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Fig 1. Medical schools and the academic mission
a salary of $179,000, and this number increases to $626,000 to cover the salary of a full professor. As academic practice has grown dependent on clinical revenues, payers have not differentiated between private and academic practice. A quick review of the Medicare fee schedule3 for some of the more common surgical procedures immediately reveals the challenge (Table IV). Even with the trivial increase for some procedures in the past year, fees for clinical services remain so low that a private practice mentality dominates the academic center. 80-hour work weeks combining clinical work with research and/or education have been replaced by 80 hours of pure clinical effort. It is essential that I state that the issue is not personal compensation but failure to secure alternative sources of support for the academic mission during this period of declining clinical revenues. Compensation levels remain an issue only in that adequate compensation is required to attract and retain the exceptional talent needed to carry out our complex job description. The real irony in the changes that have occurred over the past decade is that not only have the academic opportunities for university surgeons diminished, but due to higher overheads in many academic programs, university surgeons are forced to generate more clinical revenue than even their private practice counterparts in order to secure a lower level of compensation. Lest I be accused of delivering an entirely negative message, I should point out that some relief is in sight. Medicare payment rates appear to have stabilized, and the National Institutes of Health’s (NIH) budget continues to grow. A significant increase in
the NIH salary cap to $161,200 offers university surgeons, for the first time at least, the possibility of securing enough salary support from NIH grants to adequately cover expenses. But have the research infrastructure and academic pipeline been so wounded that they cannot recover? More important, have the unique needs of surgeons in terms of training duration, time demands, and clinical areas of importance really been addressed? When will the value of educational mission be recognized? Before I consider, in the next section of my talk, some of the factors that have contributed to the current state, I want to emphasize a very important point. We are still in a relatively young field that, in truth, has known nothing but rapid change. The university surgeon who bemoans the rapid changes we now face fails to appreciate the pace of change in our profession. Just consider the state of surgery 100 years ago. Ether anesthesia had been identified only a few decades earlier, the American Surgical Association had just formed, and the first Halsteadtype residency had been established at Johns Hopkins. The American College of Surgeons, the American Board, and the SUS did not exist, and all of what would become the great accomplishments of the 20th century were considered out of reach. Operating theaters bore minimal resemblance to the high-tech facilities of today. The lesson is clear: change is constant and must be embraced. But not all change has been positive, and both society and academic physicians, including surgeons, must take responsibility for the current state of academic medicine. The noted medical historian Keith Ludmerer perhaps states the second point of this address best in his
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Table V. The university surgeon as advocate • Be a builder—have a programmatic focus • Align your objectives with the department and medical center • Seek appropriate rewards • Use all available portals for advocacy • Take others with you
recent book Time to Heal–American Medical Education from the Turn of the Century to the Era of Managed Care. Concerning the past decade, he writes: As the millennium approached, the learning environment in academic health centers was eroding, faculty research was decreasing and faculty incomes depended mainly on the private practice of medicine rather than on teaching and research. The social contract between society and medical education had been broken. Society was no longer providing academic health centers with sufficient financial or political support. In turn, medical faculties had grown inwardly focused.4
His conclusions are clear. The great successes in academic medicine of the 20th century were a consequence of a partnership between society and medical schools. The loss of this connection contributed to a loss of public support for our mission, and instead of rebuilding a support base, the academic physician has grown ever more insular, circling the wagons to protect resources as autonomy vanished and incomes became threatened. THE FORCES OF CHANGE There have been many forces, most of them financial, that led to the academic crisis of the 1990s. Understanding these forces and the rapid pace of change in academic medicine is critical to charting an effective course for the future (Fig 1). At least some of the origins extend back to the late 1800s, when many of the medical schools in the United States were proprietary, in that they were private, for-profit schools that paid little attention to admission criteria and gave no direct exposure to patient care. The deplorable state of medical education in the United States at the turn of the century was detailed in 1910 in the famous Flexner Report, which called for sweeping changes.5 Using the recently established Johns Hopkins School of Medicine as an example, Abraham Flexner proposed that patient care, education, and research should be part of university-based programs and serve as the foundation of medical education. This report had dramatic effects often referred to as the first revolution in US medical education. Understanding the potential benefit to the public
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health, society embraced the mission outlined by the report and provided the support for universities and medical schools through government spending and philanthropy. A number of outstanding medical schools originated in this period as proprietary schools vanished. Education became the dominant theme within these university-based schools. Patients benefitted, because hands-on patient care became part of the teaching method. As the quality of doctors improved, a powerful bond developed between the public and medical schools. The Flexner report had also clearly identified the importance of research to the advancement of the academic mission, and with the increased governmental and public support, medical schools had become fully invested in the research enterprise. By the time the NIH was established in 1930, the United States had become the world’s leader in biomedical research. The bond between society and medical schools remained strong as one amazing discovery after another emanated from the great universities of this country. The NIH budget started to grow exponentially and between 1930 and 1966 was the financial force behind the academic missions. Society supported the mission of academic health systems, and faculties clearly understood that implicit within their position was a major element of public service. Although research had become a dominant theme in the 1940s and 1950s, the commitment to education remained strong. Both the good news and the bad news was that the decades of investment in research paid off. Through advancements in technology, patients with chronic disease began to live longer, and new effective, but expensive, therapies became commonplace. In the 1960s, Medicare and Medicaid began to pay rising costs, which introduced the most powerful financial force yet—clinical revenues. Medical schools responded by increasing faculty sizes, as well as clinical volume, to take advantage of this new source of revenue. Patient care, as a clinical service, as opposed to a vehicle for the educational mission, became the dominant theme. Annual medical spending in the United States increased rapidly. Starting at $27 billion per year in 1960, spending has nearly tripled in every decade since. Medical expenditures as part of the gross national product increased from under 5% to nearly 15% in this period. The change was also seen in mean faculty salaries. Ranging from $18,000 to $28,000 per year in the 1960s, surgeon salaries grew tenfold, to the current levels6—a growth beyond what can be explained simply by inflation.
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As health care costs grew, physicians were chided for their inability or unwillingness to control patient care costs. This led to the introduction of managed care, starting in the early 1980s with the institution of diagnosis-related groups, which did not fully take hold until the early 1990s. This rapid introduction of managed care has been referred to by some as the second revolution in American medical education. A second and extremely important consequence of the change in the focus of US medical schools from education and research to clinical care has been a clear disruption in the social bond between medical schools and the public. In the era of plenty, faculties grew aloof, and as the reins tightened, all sectors of the medical community attempted to build firewalls to protect their shrinking sources of revenue. THE NEED FOR ADVOCACY With these thoughts in mind, the final and most important message I would like to deliver is that now, more than ever, the success of our mission as university surgeons requires advocacy to rebuild our bond with society. By advocacy, I mean reaching out to educate individuals, groups, and organizations about the importance of our mission. There are many compelling reasons for an aggressive advocacy campaign. Society must be continuously reminded that what we do is extremely important. The evidence is written in the stories of millions of lives that have been positively impacted through the contributions of university-based surgeons. Major advances have followed years of struggle and have come only through the perseverance of a small community of dedicated academic surgeons. Our mission is indeed costly and requires access to resources that are growing ever more scarce in an environment in which there are many competing interests. Change is constant and rapid, and a failure to act leaves our fate to the growing administrative hierarchies that increasingly control resources. We need strong advocacy, because we represent a minority even within the profession of surgery. Based on the rosters of the SUS, university surgeons account for only 3% of surgeons practicing in general surgery and the specialties relevant to our Society. Who will act as advocate for the university surgeon and his or her mission? I propose that there are 3 major forces for change—the individual surgeon, academic departments, and societies, such as the SUS. All these groups must understand that there are numerous portals for advocacy, and we are presented with opportunities almost daily, start-
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Table VI. The academic department as advocate 1. Department leadership must define the missions 2. Department missions must have value to the public: • Excellent clinical programs • Education • Clinically relevant research 2. Publicize the mission: use information technology 3. Set the standards for patient care • Outcomes research 4. Create a positive environment for students and residents 5. Advocate for the academic mission within the system
ing with patients and their families, and extending to payers, students, and even the governmental bodies that regulate our lives. All the constituents of our professional lives must be continuously educated on the value of the academic mission. Advocacy must start with the individual surgeon (Table V). The first step is to be a builder. By a builder I mean someone who develops something of unique value, whether that be a successful research program or a busy clinical practice with programmatic focus. Increase your value by aligning your objectives with the overall goals of the department and medical center. Only by having a position of value and authority within your own environment can you have a voice that is heard. As you build successful programs around yourself, it is important to continue to seek appropriate rewards. Simply translating your success into higher personal income sends the wrong message and will not benefit the overall academic mission, and it may not even provide long-term security. Competitive compensation levels coupled with other rewards, such as accelerated academic promotion and greater authority within your environment, will have lasting impact. Use all of the available portals, again starting with patients. Use the patient as advocate, and at the same time, be the champion of patient issues. Do not forget to take others with you in this process. Remember, you are a role model and take pride in generating enthusiasm for the opportunities in academic surgery. To paraphrase my mentor, Richard Simmons, the best way to receive credit and enhance your own standing is to give credit to others. To be insular in this era, even in your own environment, is academic and professional suicide. Academic departments are also in a position to serve as advocates (Table VI). Advocacy at the department level must start with the leadership clearly defining department priorities and objectives that have obvious value to the public and
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Table VII. SUS as advocate: opportunities • Active participation in more influential academic organizations: AAMC, ABS, ACS • Public information campaign • Lobby governmental agencies • Form policy consortium with other academic surgical societies
include the traditional missions of exceptional clinical programs, education, and clinically relevant research. Information technologies should be used to publicize departmental programs. Academic departments working alone or in consortiums need to place even greater emphasis on the importance of outcomes research. Not only patients, but also patient advocacy groups and payers understand the importance of optimizing therapies—setting the standards of care within your own health care system and the country, in a sense. An example of the importance of this type of advocacy was seen recently in a statement released by the Leapfrog Group, a consortium of Fortune 500 companies that provides health care benefits to some 20 million Americans and spends nearly $40 billion dollars a year on health care.7 With the goal of reducing medical errors, this panel defined criteria for providers that contracted for health care dollars in their companies. Recommendations included computerized physician order entry, evidence-based hospital referral, and 24-hour intensive care unit staffing by critical care specialists. We have used the Leapfrog report as an argument to enhance the intensive care unit coverage in some of our hospitals. Evidence-based research can have a great impact on payers if we have the support of powerful groups such as these. Education must remain on the forefront of the departmental mission. This includes not only educating medical students but also the next generation of surgeons. Departments must develop innovative methods for training surgeons outside of the operating room to dispel the concerns within society that resident surgeons practice their operative skills on patients. At the University of Pittsburgh, like many institutions, we are building an education center for the instruction in basic and minimally invasive surgical techniques. We have launched a publicity campaign to raise the awareness of the public to our training mission and to generate revenue to support the center, not only from the public but also industry and our own health care system. This center bears the name of the late Charles Watson, a great surgeon educator in our department. Within departments, an emphasis must be placed on creating an environment with positive role mod-
els, while remembering that our words and actions will profoundly influence the decisions our students make. The department leadership and the entire department must also act as advocate for the academic mission within the regional system. Health system administrators must be made to understand the importance of academic success within the department to the system. The relationship is clear: “academic success attracts new talent and talented university surgeons bring the motivation, skills, and ingenuity needed to build effective programs.” Finally, our academic surgical societies have not been adequately exploited for an advocacy role (Table VII). One may ask why the SUS should act as advocate when so many other advocacy groups for physicians and surgeons exist. The answers are clear. Among surgeons, university surgeons are a minority. Other more general academic medical organizations have not addressed the unique needs of the university surgeon. Just consider the issue of NIH peer review and the ongoing struggle to assure surgeon and scientist representation within the NIH peer-review process. And finally, only the SUS, along with the American Surgical Association and the Association for Academic Surgery, truly represent the university-based surgeon. Like most academic societies, the SUS has focused its attention inward within recent years. Last year, President Beauchamp spoke of the need for academic surgeons to evolve in a complex environment.8 Two years ago, President Cioffi called for leadership and mentorship in these challenging times.9 These timely and important messages spoke of the importance of change within ourselves to provide the leadership essential to ensure our continued success as university surgeons and as a Society. As we heed these important messages, it is now time to expand our efforts outside of the Society and to use the SUS as a powerful tool for advocacy. Thanks to visionary leadership, changes have been made in recent years that position the SUS to become a more effective advocate. Active membership has been extended to age 50, which permits greater individual participation in advocacy efforts. The annual meeting has been enhanced to better meet the needs of the members and permit a greater mentoring role by including the residents’
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program in the main meeting. The recent institution of an annual 2-day strategic planning meeting and a proposal to form a separate membership committee are moves that permit the council to invest more time on other issues, such as advocacy. There are multiple potential avenues for the SUS to act as advocate. The most straightforward is active participation in the more influential national organizations, such as the AAMC, the American Board of Surgery (ABS), and the American College of Surgeons (ACS). These national organizations have greater resources at their disposal. The AAMC is the national advocacy group for the academic mission. However, academic surgeons have had a limited voice within the AAMC. Dr George Sheldon, SUS member and head of the Council of Academic Societies, presents the SUS with a golden opportunity to become more influential within the AAMC. Toward this end, the SUS council has proposed a number of significant changes in our interaction with the AAMC, as well as with the ACS and the ABS. The SUS sends 2 representatives to each of these organizations. In recent years, these representatives have served primarily as a one-way conduit, providing information back to the SUS on ongoing activities in these other organizations. In a concerted effort to promote two-way communication, the council has extended the involvement of these representatives. Now, one each will participate as members of either the Committee on Social and Legislative Issues or in the Committee on Education. In the future, these SUS representatives will bring to the appropriate committees and the council issues on the forefront within the AAMC, the ABS, or the ACS for consideration. The committee will then prepare position statements. The proposed sequence of events is as follows. During the February council meeting, the council will identify the key issues for consideration by the committees. In the intervening time, the committee members, including the representatives, will draft position statements that will be brought forth during the June planning meeting. The drafts will be appropriately modified during the planning session and then distributed to the membership during the summer for feedback. During the October council meeting, the final statements will be approved by council, and the representatives will convey the SUS position to the appropriate body and seek feedback. This first small but significant step toward SUS advocacy represents a significant departure from business as usual. However, the seeds for this movement were planted by Bill Cioffi 2 years ago, and it
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is not too different from the proposal made in 1984 by a past president, Bernard Jaffe, during his presidential address.10 His call for advocacy was followed by a similar suggestion for greater participation of the SUS representatives. In order for this approach to be effective, the council and future leaders of the SUS will need to support and promote these changes. Other opportunities for SUS advocacy should also be considered. The SUS could use its Web site as an information resource about university surgeons to be used by individual surgeons, departments, and other societies. Consideration should also be given to a lobbying effort. Combining resources with other like-minded societies, such as the ASA or the AAS, through the formation of policy consortiums would add the weight of both numbers and influential surgeons to an advocacy effort. There are several themes important to the academic mission that future SUS leadership should consider addressing as part of an ongoing advocacy effort. Topics include greater surgeon and scientist representation in NIH peer-review processes, more support for surgical education, and loan-forgiveness programs that take into consideration the unique needs of young surgeons and scientists. Finally, the Society should advocate for greater NIH support for outcomes research. Effective advocacy will require that we learn a new way of thinking—a departure from the traditional insular behavior of academic surgeons and a move toward self-promotion. The only thing that is certain is that change is constant. The failure to adequately react in the past must be placed behind us. History should teach us that unless we are willing to step forward and actively participate on a national level in our own destiny, our destiny will be determined by short-sighted individuals more concerned with immediate financial bottom line than the long-term impact of their decisions. I state again, this cannot be about personal compensation; it must be about the resources and the support needed to complete a complex mission, a mission that only a relative few highly motivated, dedicated, and exceptionally talented individuals can achieve. If we have not learned anything else in recent years, we must understand now that we cannot achieve this mission without the support of the public. The last decade has been most challenging for academic surgery. However, the new millennium presents new opportunities to those willing to actively participate in their own destiny. Therefore, I conclude by urging each member, departmental leader, and leader of this Society, to become an
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active advocate for the academic mission of university surgeons. In closing, let me again express my gratitude to the membership for the honor of serving as president of this esteemed Society. REFERENCES 1. Thompson JC. Presidential address: gifts from surgical research. Contributions to patients and to surgeons. Clinical Congress of the American College of Surgeons. American College of Surgeons 2000. p. 391-403. 2. AAMC Publications and Information Resources: AAMC Data Book. 2000. 3. Medicare Special Bulletin. November 17, 2000. 4. Ludmerer KM. Introduction. In: Time to heal, American medical education from the turn of the century to the era of managed care. New York: Oxford University Press; 1999. p. 25.
5. Flexner A. Medical education in the United States and Canada. New York: Carnegie Foundation for the Advancement of Teaching; 1910. 6. Ludmerer KM. Faculty salaries, 1965. In: Time to heal, American medical education from the turn of the century to the era of managed care. New York: Oxford University Press; 1999. p. 155. 7. Birkmeyer JD, Birkmeyer CM, Wennberg DE, Young M. Leapfrog Patient Safety Standards: the potential benefit of universal adoption. The Leapfrog Group for Patient Safety Rewarding Higher Standards. Sponsored by the Business Roundtable. November 2000. 8. Cioffi WG. Presidential address: SUS mentorship in Y2K–passion, leadership, perspective. Surgery 1999;126:10111. 9. Beauchamp RD. Presidential address: evolution. Surgery 2000;128:123-32. 10. Jaffe BM. Presidential address: how big the bite? Surgery 1984;96:129-32.
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