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Problems in the training of surgeons and in the practice of surgery
Problems
in the Training
and in the Practice WILLIAM
of Surgery
P. LONGMIRE, JR., M.D.,Los Angeles,
California
their parent University. The changes made during that period elevated medical school education in this country essentially to the plane it occupies today. After some semblance of order had been brought out of the chaotic educational pattern in medical schools, a concern developed for improving standards of postgraduate or specialty training in America.
From the Department of Surgery, University of California, School of Medicine,Los Angeles, California. CC
of Surgeons
THE SURGEON be well educated, skillful, LETready and courteous. Let him be bold in
those things that are safe, fearful in those that are dangerous ; avoiding all evil methods and practices. Let him be tender with the sick, honorable to men of his profession, wise in his predictions; chaste, sober, pitiful, merciful; not covetous or extortionate; but rather let him take his wages in moderation, according to his work, and the wealth of his patient, and the issue of the disease, and his own worth.“*
STANDARDSFORPOSTGRADUATE
TRAINING
The length of surgical training programs in various countries throughout the world seems to depend on two factors: F‘ist, and most important, are the opportunities that the country provides for the individual to practice, both in terms of facilities and financial remuneration, and second, the requirements established by some authoritative body, either governmental or nongovernmental, that regulate the content, extent, facilities, and number of training programs. In the developing years of our great country there was little other than an individual’s conscience (and his ability to persuade his patient to submit) that limited the forays of any doctor into the field of surgery. A state license awarded after an uncertain amount of exposure to “medical school,” permitted him to practice “medicine and surgery.” Until about 1920, there was very little to encourage a man to tarry long to prepare himself for the practice of surgery. Even if he wished to do so, such training positions were rarely available in this country. If sufficient resources were at hand, he might go abroad, for in some centers in Europe the clinical material for surgical training was abundant. It is interesting, however, that these training opportunities abroad were
MEDICAL SCHOOLSTANDARDS
During the latter half of the nineteenth and the early years of the twentieth century, hundreds of small settlements had sprung up in this country and new medical schools had been created with amazing rapidity to turn out hastily prepared doctors to serve these numerous, rugged, isolated communities. There was nothing in this country at that time to regulate the number, the quality, or the products of these schools. At one time there were 180 medical schools. Now, with more than double the population, there are eighty-three approved four year schools. At the turn of the century, most of the states required a high school diploma and a passing grade in the State Medical Examination for a license to practice medicine. Some required a medical degree, many did not. With the Flexner Report of 1910 spearheading the drive, marked changes were made in medical education. The number of weaker medical schools was drastically reduced, and those that remained were brought closer to * Grande Chirurgie, Guy de Chauliac, 1363. 16
Ameriran
Jouvnal of Surgevy
Training
in the Practice
strictly for foreigners: Americans and others. Such training was available to a very limited number of the native European doctors who wished to become surgeons and practice in the same European country in which they trained. It seems likely that Dr. William Halsted, who is generally considered as the father of our American residency training system, was trying to introduce the German “Oberartz system” when he established the first surgical residency in America. Frequently, under this system, the chief house officer lived and worked in the hospital for years until he was “called” to be chief of a surgical service elsewhere. Indeed, some of Halsted’s early residents remained as “chief” for several years. But soon the opportunities for his residents were so attractive elsewhere that the period of chief residency was decreased to one year, and this has served as the pattern for all American residency programs since. With the exception of the fields of ophthalmology and otolaryngology, in which qualifying boards were established about 1920, the majority of surgical specialty boards were established around 1935. The slender thread of authority or influence possessed by these nongovernmental, “voluntary” bodies is well known and there have been repeated attempts, backed by men with a variety of motives-some honorable but misguided; others both misguided and dishonorable-to destroy or to dilute the “none too high” standards which these bodies have so arduously created. PRESENT
REQUIREMENTS
AMERICAN
OF THE
BOARD OF SURGERY
The American Board of Surgery, which concerns itself with the qualifications of general surgeons, requires evidence of the satisfactory completion of an approved internship and four years of approved residency training, including a senior year, or three years in a so-called “type II” program followed by two years of approved preceptorship training. It is not known how the period of four years was selected. At the time the requirement was initiated it must have seemed like a very long training period that the Board was establishing, for the training requirements of the American College of Surgeons at the same time were one year of internship and two years as a surgical assistant, or an apprenticeship of equivalent value. When the Society of University Surgeons was organized in 1938, there were only ten Vol. 110. July
1965
17
of Surgery
surgical residency programs acceptable to that group in the United States. During World War II many good surgeons were trained in the twenty-seven month programs, who technically could perform a gastrectomy or other major operations with great skill. Interestingly enough, many of these men returned for further residency training as soon as they were released from military duty, despite the fact that they had supposedly completed the chief residency, and despite the fact that some had served in good hospital-surgical assignments during their period on active military duty. These men were the first to recognize the narrow and sketchy training they had received in a twenty-seven month program. FUTURE
TRAINING
PROGRAM
If one accepts the training program proposed by the Committee on Graduate Training in Surgery of the American College of Surgeons, trainees in all fields of surgery should take two years of training that would expose them to the major surgical divisions before entering the t.raining program of a particular surgical specialty. In general surgery, for example, a trainee would start with two years of basic surgical training to be followed by at least three more years in general surgery, a minimum of five years. The four year program required by the American Board of Surgery is, of course, the minimum requirement for the training of an average “safe” general surgeon. The small number of programs that have gone beyond the “average,” however, is surprising. Therefore, it would seem that in a good university surgical service of the future, a man would spend two years in “basic surgery”; one to two years in a basic science or investigative project either at the beginning or end of his residency program or a year in some field of special interest in clinical surgery; a fourth or fifth year as junior resident on the service ; a fifth or sixth year as first assistant divided between private and nonprivate cases; and a final, or sixth or seventh year, as chief resident. In the future a five year program would seem to afford minimal training in general surgery, with one or two additional years added if research experience or special clinical training is desired. By way of contrast, there is at present one large, fully qualified “Board” which requires only eighteen months of surgical training
18
Longmire
for a doctor to be certified as a specialist in one form of abdominal surgery. HOUSE
S,TAFF SALARIES
Most men who are in training, or who have just finished their training, and are still trying to pay the debts incurred during this period, will throw up their hands in horror at the thought of lengthening the surgical training program. But as part of this extended program, doctors in training must be paid a “better than living” wage from the time they finish medical school. The exact amount of such salaries will, of course, vary from city to city. In our institution a senior technician and a resident are paid approximately the same salary. The qualifications for senior technician are graduation from college with a major in an applicable science, and one year of graduate study or its equivalent. The resident, as you know, has three or four years of college, four years of medical school, one year of internship, and two to five years of residency training. The senior technician, if he is a good one, well deserves his salary and is worth every cent he is paid. The resident is grossly underpaid. The time has passed when a man was willing to “starve” for a few years, because he knew he could “make it back” and more in fifteen to thirty years of good active surgical practice. Taxes have taken the peak from his income during his most productive period. Steps should be taken to try to smooth out the earning curve at the other end, too, by eliminating the debt ridden years of housestaff training. Society has not been made to recognize the magnitude of the medical and surgical care that it is obtaining at substandard rates from the 36,000 residency positions in over 1,400 hospitals throughout the country [I]. The time has passed when young men in medicine can be expected to make this vast contribution to society and be satisfied with the explanation that in this way they are paying for the privilege of learning, or paying their tuition for postgraduate schooling. OVERCROWDING
IN CERTAIN
SPECIALTIES
There are numerous signs that, in some fields, we are training too many specialists. Since its founding in 1937, there have been over 11,000 surgeons certified by the American Board of Surgery, and each year approximately 700 new
diplomates are added to this number. Over 1,000 applicants whose credentials are in order are accepted for examination each year. In a survey in California three years ago [2], the “opportunities” for various specialists in the State were summarized in categories as: excellent, very good, good, fair, poor, and very poor. General surgery and one other specialty were the only two listed in the “very poor” category. In the past two years the opportunities have been rated as “fair.” Such an evaluation, if correct, would seem to imply that the supply of trained surgeons is greater than the demand. Although comparable surveys in other states are not known, the impression is gained that a similar situation prevails in many areas of our country; and, indeed, this present surplus of general surgeons has been documented by a recent survey conducted by the American College of Surgeons. Questionnaires were sent to all of the Fellows of the American College of Surgeons and 13,477 replies were received. One of the questions asked, in this largest medical survey ever conducted, concerned an evaluation of the medical manpower supply in various specialties in the Fellow’s own communities. Among the respondents answering this question, 6,685 thought there were too many general surgeons, 5,067 thought therewere just enough and 343 believed more general surgeons were needed. This type of response came from specialists outside of the field of general surgery as well as from the general surgeons. For example, the responses from neurosurgeonswere as follows : 186 thought there were too many general surgeons in their communities, eighty-one believed the number was just right, and four indicated there were not enough [3]. In a free society the law of supply and demand will adjust such discrepand supposedly this ancies automatically, situation will eventually conform; but in the meantime many well trained men are going to suffer as a result of this overcrowding. As far as is known, there are no good statistics concerning the number of trained surgeons that this country actually needs, but there are many indications that under present conditions we are certifying too many. One means of begging the question is to say that the country can always use more better trained surgeons. Such platitudes are meaningless unless the corollary is added that operations should be performed by no one other than fully trained and certified surgeons. Such restrictions on a national level American
Journal of Surgery
Training
in the Practice
have thus far been established only in countries that we would consider to have “socialized medicine.” From the practical point of view it seems that whatever plans we make for surgical care in this country, we must accept the fact that a vast amount of surgery for some years to come will be performed by doctors with less than a full formal surgical training. One means of attempting to adjust this current oversaturation might be to maintain approximately the same number of approved senior residency positions at least for the next five years, and thus allow the general population increase to reduce the surgeon-population ratio. During this period there would continue to be a turnover in approved residency programs as weak programs are eliminated and replaced by stronger services. The current total of 498 approved Type I and Type II general surgery training programs which provide 6,027 residency positions at all levels would be maintained at approximately the same level. One of the greatest paradoxes of our times is the overwhelming zeal of almost every surgeon to be a teacher. Practically every hospital of 200 beds or more in this country seems bent on having an approved surgical residency program. One wonders if there is any other group in our society as dedicated to training their competitors as surgeons. The vast majority of surgeons who complete their training in the smaller hospitals remain to practice in that hospital or in the immediate vicinity. Some training programs are initiated because of a sincere desire on the part of a number of staff surgeons to engage in teaching. Some programs are started for their “prestige value” in the community, and some, unfortunately, merely to obtain the services of a group of residents to do the “scut work.” At the end of the war a great number of training programs were hastily set up and approved to take care of the swarm of returning potential surgeons. Some of these have been maintained as excellent training programs. Other programs were weak to start with and have never improved. Ways must be found to identify such programs fairly and to eliminate them. The idea must also be widely accepted that a hospital does not have to be in the “training business” to be a good hospital. Those who have served on residency review committees know that there are approved training programs today that are grossly inadequate, but to Vol. 110. July 1965
of Surgery
19
obtain documented evidence of this inferiority is often extremely difficult. In the training of general surgeons some factors we must then consider are: (1) Should our training programs in general surgery start with two years of broad surgery and be lengthened to five, six, or seven years? (2) Should not the intern be paid a living wage in all of our hospitals with a substantial increase to the residents each year thereafter? (3) Should we reduce by one hundred the available approved senior general surgical residency positions? ECONOMICS
Most surgeons will agree that the general trend in professional fees in recent years has been for the surgical fee to be equalized in relation to the fees of other specialties. It seems that almost every time an insurance or medical society fee schedule is proposed, there is a further tendency toward such equalization. Obviously, this is a subject about which doctors have strong emotional feelings, and about which there is a very sharp dividing line of opinions. This clear-cut dividing line is simply whether the doctor in question does or does not operate. If a doctor operates, surgical fees are too low. If he does not, they are too high. It must be agreed however-be it right or wrongthat per unit of service performed, surgical fees are among the highest in our profession. LACK OF EFFICIENT OF TRAINED
UTILIZATION
SURGEONS
Another important aspect of this problem concerns the number of physicians who are working at a pace far below capacity. A number of young surgeons have said that as they go through Osler’s early “bread period,” their income actually has been modest but adequate, but the thing that bothers them most is the inactivity of their hands and minds. Our surgical residents are given a start in life with a busy, demanding, crowded operative schedule, a pace some residents never equal again in their lives. Certainly a great letdown occurs in the first years in practice. It is true that in each community in our country there are a few surgeons who are doing all or more than they can humanly do. Many, though, are working at a pace far below their capacity, and this is a tremendous waste of highly skilled talent. The only excuse one can find for it is that it provides a large reserve pool of highly trained specialists
20
Longmire
available to the country in time of national emergency. It may be accepted as one of the ineficiencies of a democracy, but in a few years this “pool” may well become a luxury that this country cannot afford. In summary, then would it not be more logical and eEcient to create fewer specialists but keep them busy at their chosen work and accept a certain adjustment of fees. Also, should not this country eventually look forward to the elimination, by regulation, of any surgical activity on the part of those physicians not fully
trained and accredited? Obviously, such a change would have to come about gradually over a period of years. REFERENCES 1. Directory
of Approved Internships and Residencies American Medical Association, Chicago,
1963. Illinois. 2. Facts about Medical Practice in California 1961, 1962. California Academy of General Practice, San Francisco, California. 3. Report of Committee on Surgical Practices, page 6, October 11, 1962. American College of Surgeons, Chicago, Illinois.
American Journal of Surgery
in the Training
and in the Practice WILLIAM
of Surgery
P. LONGMIRE, JR., M.D.,Los Angeles,
California
their parent University. The changes made during that period elevated medical school education in this country essentially to the plane it occupies today. After some semblance of order had been brought out of the chaotic educational pattern in medical schools, a concern developed for improving standards of postgraduate or specialty training in America.
From the Department of Surgery, University of California, School of Medicine,Los Angeles, California. CC
of Surgeons
THE SURGEON be well educated, skillful, LETready and courteous. Let him be bold in
those things that are safe, fearful in those that are dangerous ; avoiding all evil methods and practices. Let him be tender with the sick, honorable to men of his profession, wise in his predictions; chaste, sober, pitiful, merciful; not covetous or extortionate; but rather let him take his wages in moderation, according to his work, and the wealth of his patient, and the issue of the disease, and his own worth.“*
STANDARDSFORPOSTGRADUATE
TRAINING
The length of surgical training programs in various countries throughout the world seems to depend on two factors: F‘ist, and most important, are the opportunities that the country provides for the individual to practice, both in terms of facilities and financial remuneration, and second, the requirements established by some authoritative body, either governmental or nongovernmental, that regulate the content, extent, facilities, and number of training programs. In the developing years of our great country there was little other than an individual’s conscience (and his ability to persuade his patient to submit) that limited the forays of any doctor into the field of surgery. A state license awarded after an uncertain amount of exposure to “medical school,” permitted him to practice “medicine and surgery.” Until about 1920, there was very little to encourage a man to tarry long to prepare himself for the practice of surgery. Even if he wished to do so, such training positions were rarely available in this country. If sufficient resources were at hand, he might go abroad, for in some centers in Europe the clinical material for surgical training was abundant. It is interesting, however, that these training opportunities abroad were
MEDICAL SCHOOLSTANDARDS
During the latter half of the nineteenth and the early years of the twentieth century, hundreds of small settlements had sprung up in this country and new medical schools had been created with amazing rapidity to turn out hastily prepared doctors to serve these numerous, rugged, isolated communities. There was nothing in this country at that time to regulate the number, the quality, or the products of these schools. At one time there were 180 medical schools. Now, with more than double the population, there are eighty-three approved four year schools. At the turn of the century, most of the states required a high school diploma and a passing grade in the State Medical Examination for a license to practice medicine. Some required a medical degree, many did not. With the Flexner Report of 1910 spearheading the drive, marked changes were made in medical education. The number of weaker medical schools was drastically reduced, and those that remained were brought closer to * Grande Chirurgie, Guy de Chauliac, 1363. 16
Ameriran
Jouvnal of Surgevy
Training
in the Practice
strictly for foreigners: Americans and others. Such training was available to a very limited number of the native European doctors who wished to become surgeons and practice in the same European country in which they trained. It seems likely that Dr. William Halsted, who is generally considered as the father of our American residency training system, was trying to introduce the German “Oberartz system” when he established the first surgical residency in America. Frequently, under this system, the chief house officer lived and worked in the hospital for years until he was “called” to be chief of a surgical service elsewhere. Indeed, some of Halsted’s early residents remained as “chief” for several years. But soon the opportunities for his residents were so attractive elsewhere that the period of chief residency was decreased to one year, and this has served as the pattern for all American residency programs since. With the exception of the fields of ophthalmology and otolaryngology, in which qualifying boards were established about 1920, the majority of surgical specialty boards were established around 1935. The slender thread of authority or influence possessed by these nongovernmental, “voluntary” bodies is well known and there have been repeated attempts, backed by men with a variety of motives-some honorable but misguided; others both misguided and dishonorable-to destroy or to dilute the “none too high” standards which these bodies have so arduously created. PRESENT
REQUIREMENTS
AMERICAN
OF THE
BOARD OF SURGERY
The American Board of Surgery, which concerns itself with the qualifications of general surgeons, requires evidence of the satisfactory completion of an approved internship and four years of approved residency training, including a senior year, or three years in a so-called “type II” program followed by two years of approved preceptorship training. It is not known how the period of four years was selected. At the time the requirement was initiated it must have seemed like a very long training period that the Board was establishing, for the training requirements of the American College of Surgeons at the same time were one year of internship and two years as a surgical assistant, or an apprenticeship of equivalent value. When the Society of University Surgeons was organized in 1938, there were only ten Vol. 110. July
1965
17
of Surgery
surgical residency programs acceptable to that group in the United States. During World War II many good surgeons were trained in the twenty-seven month programs, who technically could perform a gastrectomy or other major operations with great skill. Interestingly enough, many of these men returned for further residency training as soon as they were released from military duty, despite the fact that they had supposedly completed the chief residency, and despite the fact that some had served in good hospital-surgical assignments during their period on active military duty. These men were the first to recognize the narrow and sketchy training they had received in a twenty-seven month program. FUTURE
TRAINING
PROGRAM
If one accepts the training program proposed by the Committee on Graduate Training in Surgery of the American College of Surgeons, trainees in all fields of surgery should take two years of training that would expose them to the major surgical divisions before entering the t.raining program of a particular surgical specialty. In general surgery, for example, a trainee would start with two years of basic surgical training to be followed by at least three more years in general surgery, a minimum of five years. The four year program required by the American Board of Surgery is, of course, the minimum requirement for the training of an average “safe” general surgeon. The small number of programs that have gone beyond the “average,” however, is surprising. Therefore, it would seem that in a good university surgical service of the future, a man would spend two years in “basic surgery”; one to two years in a basic science or investigative project either at the beginning or end of his residency program or a year in some field of special interest in clinical surgery; a fourth or fifth year as junior resident on the service ; a fifth or sixth year as first assistant divided between private and nonprivate cases; and a final, or sixth or seventh year, as chief resident. In the future a five year program would seem to afford minimal training in general surgery, with one or two additional years added if research experience or special clinical training is desired. By way of contrast, there is at present one large, fully qualified “Board” which requires only eighteen months of surgical training
18
Longmire
for a doctor to be certified as a specialist in one form of abdominal surgery. HOUSE
S,TAFF SALARIES
Most men who are in training, or who have just finished their training, and are still trying to pay the debts incurred during this period, will throw up their hands in horror at the thought of lengthening the surgical training program. But as part of this extended program, doctors in training must be paid a “better than living” wage from the time they finish medical school. The exact amount of such salaries will, of course, vary from city to city. In our institution a senior technician and a resident are paid approximately the same salary. The qualifications for senior technician are graduation from college with a major in an applicable science, and one year of graduate study or its equivalent. The resident, as you know, has three or four years of college, four years of medical school, one year of internship, and two to five years of residency training. The senior technician, if he is a good one, well deserves his salary and is worth every cent he is paid. The resident is grossly underpaid. The time has passed when a man was willing to “starve” for a few years, because he knew he could “make it back” and more in fifteen to thirty years of good active surgical practice. Taxes have taken the peak from his income during his most productive period. Steps should be taken to try to smooth out the earning curve at the other end, too, by eliminating the debt ridden years of housestaff training. Society has not been made to recognize the magnitude of the medical and surgical care that it is obtaining at substandard rates from the 36,000 residency positions in over 1,400 hospitals throughout the country [I]. The time has passed when young men in medicine can be expected to make this vast contribution to society and be satisfied with the explanation that in this way they are paying for the privilege of learning, or paying their tuition for postgraduate schooling. OVERCROWDING
IN CERTAIN
SPECIALTIES
There are numerous signs that, in some fields, we are training too many specialists. Since its founding in 1937, there have been over 11,000 surgeons certified by the American Board of Surgery, and each year approximately 700 new
diplomates are added to this number. Over 1,000 applicants whose credentials are in order are accepted for examination each year. In a survey in California three years ago [2], the “opportunities” for various specialists in the State were summarized in categories as: excellent, very good, good, fair, poor, and very poor. General surgery and one other specialty were the only two listed in the “very poor” category. In the past two years the opportunities have been rated as “fair.” Such an evaluation, if correct, would seem to imply that the supply of trained surgeons is greater than the demand. Although comparable surveys in other states are not known, the impression is gained that a similar situation prevails in many areas of our country; and, indeed, this present surplus of general surgeons has been documented by a recent survey conducted by the American College of Surgeons. Questionnaires were sent to all of the Fellows of the American College of Surgeons and 13,477 replies were received. One of the questions asked, in this largest medical survey ever conducted, concerned an evaluation of the medical manpower supply in various specialties in the Fellow’s own communities. Among the respondents answering this question, 6,685 thought there were too many general surgeons, 5,067 thought therewere just enough and 343 believed more general surgeons were needed. This type of response came from specialists outside of the field of general surgery as well as from the general surgeons. For example, the responses from neurosurgeonswere as follows : 186 thought there were too many general surgeons in their communities, eighty-one believed the number was just right, and four indicated there were not enough [3]. In a free society the law of supply and demand will adjust such discrepand supposedly this ancies automatically, situation will eventually conform; but in the meantime many well trained men are going to suffer as a result of this overcrowding. As far as is known, there are no good statistics concerning the number of trained surgeons that this country actually needs, but there are many indications that under present conditions we are certifying too many. One means of begging the question is to say that the country can always use more better trained surgeons. Such platitudes are meaningless unless the corollary is added that operations should be performed by no one other than fully trained and certified surgeons. Such restrictions on a national level American
Journal of Surgery
Training
in the Practice
have thus far been established only in countries that we would consider to have “socialized medicine.” From the practical point of view it seems that whatever plans we make for surgical care in this country, we must accept the fact that a vast amount of surgery for some years to come will be performed by doctors with less than a full formal surgical training. One means of attempting to adjust this current oversaturation might be to maintain approximately the same number of approved senior residency positions at least for the next five years, and thus allow the general population increase to reduce the surgeon-population ratio. During this period there would continue to be a turnover in approved residency programs as weak programs are eliminated and replaced by stronger services. The current total of 498 approved Type I and Type II general surgery training programs which provide 6,027 residency positions at all levels would be maintained at approximately the same level. One of the greatest paradoxes of our times is the overwhelming zeal of almost every surgeon to be a teacher. Practically every hospital of 200 beds or more in this country seems bent on having an approved surgical residency program. One wonders if there is any other group in our society as dedicated to training their competitors as surgeons. The vast majority of surgeons who complete their training in the smaller hospitals remain to practice in that hospital or in the immediate vicinity. Some training programs are initiated because of a sincere desire on the part of a number of staff surgeons to engage in teaching. Some programs are started for their “prestige value” in the community, and some, unfortunately, merely to obtain the services of a group of residents to do the “scut work.” At the end of the war a great number of training programs were hastily set up and approved to take care of the swarm of returning potential surgeons. Some of these have been maintained as excellent training programs. Other programs were weak to start with and have never improved. Ways must be found to identify such programs fairly and to eliminate them. The idea must also be widely accepted that a hospital does not have to be in the “training business” to be a good hospital. Those who have served on residency review committees know that there are approved training programs today that are grossly inadequate, but to Vol. 110. July 1965
of Surgery
19
obtain documented evidence of this inferiority is often extremely difficult. In the training of general surgeons some factors we must then consider are: (1) Should our training programs in general surgery start with two years of broad surgery and be lengthened to five, six, or seven years? (2) Should not the intern be paid a living wage in all of our hospitals with a substantial increase to the residents each year thereafter? (3) Should we reduce by one hundred the available approved senior general surgical residency positions? ECONOMICS
Most surgeons will agree that the general trend in professional fees in recent years has been for the surgical fee to be equalized in relation to the fees of other specialties. It seems that almost every time an insurance or medical society fee schedule is proposed, there is a further tendency toward such equalization. Obviously, this is a subject about which doctors have strong emotional feelings, and about which there is a very sharp dividing line of opinions. This clear-cut dividing line is simply whether the doctor in question does or does not operate. If a doctor operates, surgical fees are too low. If he does not, they are too high. It must be agreed however-be it right or wrongthat per unit of service performed, surgical fees are among the highest in our profession. LACK OF EFFICIENT OF TRAINED
UTILIZATION
SURGEONS
Another important aspect of this problem concerns the number of physicians who are working at a pace far below capacity. A number of young surgeons have said that as they go through Osler’s early “bread period,” their income actually has been modest but adequate, but the thing that bothers them most is the inactivity of their hands and minds. Our surgical residents are given a start in life with a busy, demanding, crowded operative schedule, a pace some residents never equal again in their lives. Certainly a great letdown occurs in the first years in practice. It is true that in each community in our country there are a few surgeons who are doing all or more than they can humanly do. Many, though, are working at a pace far below their capacity, and this is a tremendous waste of highly skilled talent. The only excuse one can find for it is that it provides a large reserve pool of highly trained specialists
20
Longmire
available to the country in time of national emergency. It may be accepted as one of the ineficiencies of a democracy, but in a few years this “pool” may well become a luxury that this country cannot afford. In summary, then would it not be more logical and eEcient to create fewer specialists but keep them busy at their chosen work and accept a certain adjustment of fees. Also, should not this country eventually look forward to the elimination, by regulation, of any surgical activity on the part of those physicians not fully
trained and accredited? Obviously, such a change would have to come about gradually over a period of years. REFERENCES 1. Directory
of Approved Internships and Residencies American Medical Association, Chicago,
1963. Illinois. 2. Facts about Medical Practice in California 1961, 1962. California Academy of General Practice, San Francisco, California. 3. Report of Committee on Surgical Practices, page 6, October 11, 1962. American College of Surgeons, Chicago, Illinois.
American Journal of Surgery