Surgical Education: Foundations and Values

SOUTHERN SURGICAL ASSOCIATION PRESIDENTIAL ADDRESS

Surgical Education: Foundations and Values James A O’Neill Jr, MD, FACS As I examined the archives of the Southern Surgical Association in preparation for this address, I was surprised to learn that our various Presidents only rarely dealt with surgical education, even though the continuing education of surgeons was the motivating factor in the minds of our founders, Drs William and John Davis, in 1887. Only 9 of 118 earlier addresses have had this focus, presented every 10 to 15 years, and appropriate to their times. Because many changes in the structure of surgical education have occurred in recent years, some good and some questionable, I chose to focus on this subject. I have been involved in surgical education my entire professional career, and have had responsibility for residency programs at Penn and Vanderbilt. Additionally, I have become acquainted with the intricacies of surgical education through various organizational committees and in 17 years on the American Board of Surgery. At this point in my life, I believe I know the ingredients of a good residency program and particularly those things that have to do with the molding of a fine surgical professional. But where did our system of surgical education begin? What has been the basis of our traditions and values? Where are we now and where do we need to go?

“sick and the miserable,” and to serve as a place where physicians and surgeons could get experience. Thus, the Pennsylvania Hospital came into being in 1755, the first hospital and first teaching hospital in America.1 It functions the same way today. There are abundant records that indicate that in the ensuing years, Bond lectured at the hospital and supervised students and practicing physicians in various aspects of medicine. But a hospital was not sufficient to round out the educational needs of the young people who wanted to become successful physicians. Two young physicians educated in Edinburgh, John Morgan, a physician, and William Shippen, a surgeon, discussed the need for a medical school in the Colonies when they were still studying in Scotland. When they returned to Philadelphia in 1765, Morgan independently presented a plan to the Trustees of the University of Pennsylvania, then known as the College of Philadelphia, for the establishment of a medical school, the first one in the Colonies.1 Most people accept that the founding of a medical school in Philadelphia was Shippen’s idea, which led to friction between him and Morgan, who preempted him by presenting his now famous, “A Discourse On the Institution of Medical Schools in America” in 1765.2 Despite the tensions between the two men, they ended up working collaboratively because they shared the conviction that the availability of quality medical education in the Colonies was vital to the future of their society. It is noteworthy that their concept was a continuum of broad-based education from medical school throughout an individual’s professional career, as expressed in Morgan’s book, “It is not only expedient but necessary, that a physician should have a general and extensive knowledge of the whole art, and be acquainted with every branch of his profession.”2 Very quickly the leading physicians in Philadelphia at the time joined the faculty of this new school, including Thomas Vaughn, Benjamin Rush, Phillip Syng Physick, and many others whose names you would recognize. The activities of the school were closely linked with the Pennsylvania Hospital, creating the modern model of medical education. It was disrupted during the Revolutionary War because Morgan, Rush, and Shippen all served as medical officers in Washington’s army. Once peace came, teaching resumed in earnest. It is useful to note that Philadelphia benefited from having a large number of citizens who were products of the Age of Enlightenment in Europe, so that scientific studies were considered a priority; Benjamin

Foundations

Our story begins in colonial America in 1751 in Philadelphia, the most sophisticated city in America at the time. The Colonies had been established for 100 years. The handful of physicians who lived there were all educated in England, and any young aspiring physician in the Colonies had to spend a few years studying overseas to round out the primitive experience they were able to get here. It was too expensive for the majority of individuals to do this. In America then, there were no medical schools and no hospitals, but at least there were visionaries and physicianleaders who involved themselves in community affairs. It was in this environment that Dr Thomas Bond, a leading physician in Philadelphia, approached Benjamin Franklin to enlist his help in establishing a hospital to care for the Disclosure Information: Nothing to disclose. Presented at the Southern Surgical Association 120th Annual Meeting, West Palm Beach, FL, December 2008. Received December 19, 2008; Accepted December 19, 2008. From the Section of Surgical Sciences, Vanderbilt University School of Medicine, Nashville, TN. Correspondence address: James A O’Neill Jr, MD, FACS, Section of Surgical Sciences, Vanderbilt University School of Medicine, Nashville, TN 37232.

© 2009 by the American College of Surgeons Published by Elsevier Inc.

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Franklin is a good example of this. This meant that the science of the day was used as a base on which the educational program was built. The only really developed basic science of the time was anatomy and that was the sole possession of the surgeons. The concept of teaching medicine from a science base was solid and has persisted through time and extended from undergraduate to graduate medical education, particularly in surgery. If one looks at the model of surgical education in surgery dating from the colonization of America, it was one of apprenticeship.1 In the good places, surgical apprenticeships were supplemented with lectures, dissections, readings, and regular presentations, beginning with the establishment of the College of Physicians of Philadelphia in 1787, modeled after the Royal College of Physicians in London. In fact, the very first scientific article read there by Dr Benjamin Rush was entitled, “On the Means of Promoting Medical Knowledge.”3 Unfortunately, in the majority of places, including most proprietary institutions, apprenticeship was the only educational ingredient. As one considers apprenticeship, it must be concluded that mentorship was key. It should also be noted that the best hospital environments for surgical education then and subsequently were those affiliated with universities. The Edinburgh background of the founders of the University of Pennsylvania School of Medicine is clearly reflected in the emblem of the school that proudly shows a thistle. It is generally accepted that the structure of education is based on adequate facilities, competent faculty, and bright eager students. As one examines the product of the efforts of Morgan, Shippen, and their colleagues, these three elements existed. These were constructive people who had a broad view of how to better their community and society. All of them spent their lives developing medical education in America; they were members of the three Continental Congresses, and they contributed to the establishment of the Medical Department of the Continental Army.1 They were truly enlightened patriots, every bit as much as Benjamin Franklin and John Adams. When the Pennsylvania Hospital opened in Philadelphia in 1755, attending physicians brought their students and apprentices with them to learn current practice, to apply dressings, and to assist in the care of the patients. In those days, physician apprentices were generally indentured for 5 years so they could be instructed in the art and practice of medicine and then they were given a certificate if they performed satisfactorily. After the establishment of the medical school in Philadelphia, science was introduced into the apprenticeship experience in the form of anatomic dissections, with surgeons taking the most interest.

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Just as elements of this apprenticeship system have persisted to the current day, a key feature of the hospitals designed for teaching was the surgical amphitheater, which was used first for anatomic dissections and subsequently to observe surgical procedures; as they did for lectures, observers paid a fee for the privilege. When the Pennsylvania Hospital opened in 1755, the nation’s first hospital also had the first amphitheater in which operations were performed in the midday hours, lit only by sunlight coming in through the glass dome. Although anatomic dissections could be carried out by candlelight in this amphitheater, operations could not. During the years, these amphitheaters became the center for surgical instruction and today most of them are used as lecture halls. It is not surprising that in this amphitheater, Dr Phillip Syng Physick demonstrated his surgical talents to the point that he is now known as the Father of American Surgery. During the next 100 years, new medical schools and new teaching hospitals were established in several major cities but, on balance, that was not a promising period for medical or surgical education because the majority of institutions were proprietary in nature and, to some degree, admission and teaching standards were deplorable.4 As the population of the United States grew between 1800 and 1850, an increased demand for physicians led to the establishment of many small medical schools of poor quality. They were simply money mills owned and operated by groups of physicians. Invariably the facilities were inadequate. In those institutions, only 2 years of apprenticeship were accepted and anyone who paid the fees was given a certificate. Of course, many decent surgeons were produced from some of these small schools, despite their inadequacy. A good example of that is Jere Crook of Jackson, Tennessee, who received an undergraduate degree from Vanderbilt in 1894, apprenticed to a California surgeon for 2 years, and observed in New York for 6 months (personal papers of Dr Jere Crook, courtesy of Dr. A Crook, Nashville, TN). Despite this seemingly inadequate educational exposure and experience, Dr Crook established a well-respected practice of surgery in Jackson, Tennessee. He performed the first appendectomy for perforated appendicitis in 1902 and was one of the founders of the Southern Medical Association in 1906. He was recognized by membership in the Southern Surgical Association in 1907. In addition, there were surgeons who responded to the public criticisms of the status of American Surgery in the mid to late 1800s at the major institutions in Philadelphia, New York, Boston, Baltimore, and elsewhere. Far and away the most important advance in surgical education came from William S Halsted, in the publication

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of an address he had given at Yale University in 1904 entitled, “The Training of a Surgeon.”5 Unfortunately, Halsted never sought membership in the Southern Surgical Association, although he was invited to do so. He attended a single meeting by invitation of Charles Mayo in 1911 and briefly discussed one paper before departing for Baltimore. The basis of Halsted’s proposal was a formalization of the apprenticeship system based on science and graduated responsibility in an undetermined number of years. Halsted’s model proposed adoption of the then existing German system of surgical training, when trainees received increasing responsibility with each advancing year. This model advocated a defined structure and standardization of training, and it introduced the concept of the pyramidal system of residency training in which some candidates would be eliminated each year, ending up with a single chief resident based on merit and accomplishment. Elements of Halsted’s model continue today. There are some who believe that Halsted adapted his educational model for surgeons from the one developed by his colleague at Johns Hopkins, William Osler. Osler’s model consisted of having one or more resident trainees at different levels closely working under the supervision and mentorship of one or more faculty members. Bedside teaching was a key feature of Osler’s concept. Regardless of whether Halsted got his ideas from his friend Osler or not, his educational program became the foundation for all subsequent surgical education. Perhaps the Halstedian concept that has been questioned the most through the years is the pyramidal system referred to here, which Churchill and others changed to a rectangular system in which the same number of individuals who enter the system graduate at the end, and this is the system currently mandated by our accrediting organizations.6 Unfortunately, at the outset, only a few institutions’ training surgeons adopted the Halsted model, and the large number of proprietary and informal training environments did not. The result was that, during World War I, the American Army Medical Department had too few appropriately trained surgeons capable of handling the new, complex injuries encountered in that conflict.7 America had not learned its lesson, because the same problem was recognized during the Civil and Spanish-American Wars. The unfavorable experience during World War I led the Army Medical Department to reorganize so that the experience in World War II was better. During World War II, and particularly after it, the potential contributions of surgery were recognized, and this prompted the creation of many more surgical training programs and multiple initiatives to improve and ensure the quality of the educational process. But even before this

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there were efforts to promote quality in the practice of surgery through dissemination of information and establishment of standards. The establishment of the American Surgical Association and the Southern Surgical Association are examples. In addition, other examples include establishment of the American College of Surgeons in 1913, the American Board of Surgery in 1937, and the Conference Committee on Graduate Training in Surgery in 1950, which later became the Residency Review Committee for Surgery. One might also say that the establishment of these latter organizations began an era of regulation, which, although good on balance, had some unintended consequences. In 1948, Robert Zollinger pointed out that postwar trends in specialization were changing the field of general surgery into a narrow specialty, and that the best solution was to promote broad training in general surgery as being essential before specialization, which of course was Halsted’s original plan.8 Around this time, a large number of specialty surgery boards were established and although they promoted excellence and standardization in their individual specialties, the end result was that they gradually separated themselves from general surgical education, and surgical education itself became balkanized. One visionary, H William Scott, President of the Southern Surgical Association in 1977, stands out because he recognized the interlocking needs of general surgery and the surgical specialties in residency training. Because of this, in 1961, Dr Scott suggested that surgeons of all types have 1 year of internship with rotations on all specialty services, as well as general surgery, followed by a 2-year basic surgical residency that was half general surgery and the other half specialties.9 This was to be followed by a basic board examination, after which surgeons would branch off into the individual specialty training programs, including general surgery, which at that time included thoracic surgery as well. In 1968, Bill Longmire chaired a panel discussion at the American Surgical Association Meeting that year entitled, “A Basic Surgical Training in Preparation for All Surgical Fields.”10 Their conclusion was that basic education in surgery should include thorough education in patient care, operative technique, and the medical science underlying a comprehension of the problems common to all fields of surgery. They believed that at least 2 years for this would be required before specialization. But participants in this panel also pointed out the need for experimentation in graduate surgical education and that such experimentation could be effectively carried out only in a teaching hospital. To some degree, our standards and regulations have stifled innovation and creativity in the design of educational

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programs in surgery, an unintended consequence in the quest for quality. In the end, the standardization and monitoring provided by the Accreditation Council for Graduate Medical Education (ACGME) has probably been a good thing, but now new variables are appearing that are providing challenges to the apprenticeship model that has served us well for ⬎200 years. It is ironic that we have seen a number of new challenges and disruptive changes in surgical education at a time when surgical education in America and the status of surgical practice is the envy of the world. By now we are all aware of the Libby Zion affair in 1984, when a young woman died in the middle of the night at New York Hospital for a variety of reasons, but it was assumed that the greatest fault came from her being cared for by an unsupervised, tired, first-year resident in medicine. This resulted in work hour restrictions being set by the State of New York and lobbying, mostly by residents in medical fields, to nationalize duty hour restrictions for residents. Although this was endorsed to some degree by surgical organizations, it was pointed out by them that continuity of care was an important principle in terms of quality patient care and education. Notwithstanding all of this, in 2003 the ACGME, which represents all medical fields, published not only duty hour restrictions, but a number of related provisions, and these were fully implemented by the Residency Review Committee for Surgery in 2004, having a profound effect on all residencies.11 It is a new era that has clearly changed our apprenticeship model. Currently, it is fair to say that full implementation of work hour restrictions in surgery has had both beneficial and unintended unfavorable outcomes. Before I discuss my views on these outcomes, I want to briefly summarize the tradition of values and ethics that have characterized the surgical profession because these considerations should be the basis of any system of education that we promote. Values

The ethics and values of medicine trace their beginnings to the expressions of Hippocrates ⬎2000 years ago. Although early physicians in India and the Middle East wrote about such things, it was Hippocrates who summarized the responsibilities of the medical profession and who also taught these values to his disciples.12 His writings were reinforced in medical literature and teaching by numerous individuals through the centuries, including Guy de Chaulliac, John Hunter, and Ambrose Paré. Because of these things, medicine received recognition as a profession, which might briefly be defined as an enterprise that has a specific body of knowledge that is used for the benefit of society. The ethical canons of Hippocrates and his successors stipulated that

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the doctor-patient relationship involves an agreement between one who is ill and one who professes to heal him. This can be expressed in another way as a physician having a specific responsibility to the patient and that the interests of the patient preempt the interests of the physician. The AMA Code of Ethics of 1847 clearly endorsed this traditional definition.13 One can certainly take from our profession’s consistent ethical tradition that the aim of the physician and medicine itself is humaneness, and the responsibility of the physician can be easily determined by examining the nature of medicine and its reason for being. There have been a number of restatements of these principles, not only by surgical organizations, but by other organizations, such as the American Board of Internal Medicine in their recent publication, Principles and Commitments.14 Until now, medicine has been identified by its values. Our values are things we have considered important and essential to our profession, and they have defined us to society. For example, in his inspiring book, Humanism and the Physician, Edmund Pellegrino, the world’s leading medical ethicist, expresses the view that medicine must have an ethical framework beyond the Hippocratic precepts to handle all of the newer developments of our day.15 He speaks to the need to educate physicians who are humanists.15 He points out that if we do not emphasize this we will not develop the morality or social consciousness necessary to handle all of the new advances in science and technology or the dialogue on health care reform. Perhaps one of the most important values that has characterized medicine, and particularly surgery, has been compassion for the patient and, at least until now, we have taught that concept well. Perhaps this has traditionally been done best by role models and mentors, and none of us have had difficulty recognizing who these people were and are. Another example of endorsement of medicine’s values came to us as we graduated from our respective medical schools, when the president of our universities conferred on us the Doctor of Medicine degree and said, “I admit you with all its rights and responsibilities.” To be specific, there were four components to these responsibilities, and they included responsibility to ourselves, to our patients, to our profession, and to society. In practical application, these ideals are well-exemplified in Harvey Cushing’s book, The Medical Career and Other Papers.16 He indicated that “it has always been difficult to become a good doctor and that the qualities of industry, manipulative skill, of perseverance, of sympathy, and of understanding have always been required.” In an address at Dartmouth, he said that “aspiring physicians must have a spirit of service, that they not be afraid of hard work, and that they have a good head, a good heart,

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and skillful hands.” He said that the ideals of the profession, then in 1930, “were no different from what they were four centuries before the birth of Christ when the Father of Medicine wrote his celebrated passages.” Cushing emphasized the increasing importance of scientific study in surgery and medicine, and he warned that “the patient and the surgeon have too close a relationship to permit the usual business relationship of tradesmen.” Hippocrates indicated that the responsibility to our profession that all of us have involves the teaching of the traditional values of medicine to subsequent generations of physicians, and I believe that as surgeons in leadership positions, the mantle of responsibility rests even more heavily on our shoulders in this respect. In a monograph entitled, Clinical Education and the Doctor of Tomorrow, Marjorie Wilson emphasizes that modern clinical education in medicine must have four thrusts, including the transfer of cognitive knowledge, development of skills, promotion of continuing scholarship and confidence, and of special note, the identification of values and attitudes, because the attitudes and behaviors of physicians express the values inherent in the profession.17 Put another way, the nation needs doctors with a broader and more sensitive view of the place and role of medicine in the larger society. In addition, Pellegrino defined humanism in a physician as encompassing a “spirit of sincere concern for the centrality of human values in every aspect of professional activity.” He went on to say that “this concern focuses on the respect for freedom, dignity, worth, and belief systems of the individual person, and it implies a sensitive, non-humiliating, and empathetic way of helping.”15 Another value that surgical organizations have embraced over time has been advocacy for what has been in the best interest of patients and medical education. For example, in the archives of our association, there are several examples of the Council taking a stand on issues of the day, including considerations related to the National Board of Medical Examiners, the American College of Surgeons, the ACGME, the American Medical Association, and various aspects of government regulation. This is only right because the mission of professional surgical associations must be consistent with that of the medical profession itself, including the goals and responsibilities I have outlined. Fortunately, the Southern Surgical Association has never assumed the posture of being a union, and it has never focused primarily on the economic concerns of our profession. This brief description of the origin and evolution of values in medicine outlines a group of principles that should serve as the base of our educational system and as a benchmark for us to judge the appropriateness of changes

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in medicine over time. The hope would be that the result of this is that physicians will continue to make a commitment to the good of the patient as their primary concern and accept that some degree of self-sacrifice is necessary to protect the patient’s well-being. One of the problems we might face in terms of our traditional values is that they can be interpreted by some on the basis of the moral pluralism that exists in our society today. Regardless of this, in the end, our patients will expect us to help them live and, occasionally, to help them die, humanely. What system of values does it take to do that and what elements of surgical education promote that end? Now that I have defined a basis for judging the outcomes of the recent changes in the process of surgical education, I would like to return to that discussion. Work hour restrictions, other issues, and possible remedies

In my effort to obtain a fair assessment of the effects of work hour restrictions, I read ⬎750 abstracts and articles published on this subject. I remind you that the 80-hour work restriction and imposed rules for resident supervision came about as the result of an unfortunate death with the assumption that a resident’s fatigue was partly responsible. Even though several studies have failed to prove this assumption and the hour limit was arbitrary, the ACGME accepted the 80 hours figure because they thought it was intuitive that a better-rested resident would make fewer mistakes and that patient outcomes would be better. Also, while this was going on, the country was wrestling with the Institute of Medicine report, “To Err is Human: Building a Safer Health System,” which resulted in criticism of quality and safety in medicine.18 The 80-hour limit did not seriously impact residents in many fields who never worked 80 hours a week on average to begin with, or those in pediatrics and internal medicine, where on-call coverage has averaged 1 night in 4 at the most. Far and away the greatest impact has been on surgical specialties, with patient volumes and other educational requirements that limit the number of residents, who have traditionally worked either every other or every 3rd night. In 2004, the Blue Ribbon Committee of the American Surgical Association endorsed the 80-hour work week and proposed measures to implement high-quality, safe patient care and, at the same time, promote an environment to reduce resident fatigue, improve family lifestyle, and allow time for legitimate personal interests.19 It is difficult to say that these are not worthy goals. Extensive literature is accumulating on how work hour limitations have affected various aspects of patient care and resident education and how new systems and approaches can accommodate to the consequences of these changes,

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both intended and unintended. I think it is fair to say that we have not achieved all that the work limitations were meant to achieve and the results have been mixed. Studies in a variety of specialties, including surgery, show that work hour limitations have resulted in less resident fatigue, a better sense of well-being, fewer motor vehicle accidents during off-duty hours, and slight improvements in surgery in-training examination scores.20 A study by Gelfand and colleagues showed a decrease in perceived stress in surgery residents after the 80-hour limit, but stress levels were still above normal levels for subjects in a control group, and burnout rates in a number of specialties have shown little change.21 The available studies of patient safety outcomes have so far been disappointing. Some show a decrease in medical errors by first-year resident trainees with work limitation, but global surgery surveys indicate some worsening of outcomes after the restrictions.22,23 The literature is mixed in terms of resident operative experience, with some studies showing no change and others showing a decrease, particularly in complicated procedures,24,25 The main untoward effects of work hour restrictions for surgical residents have been a decrease in outpatient experience, diminished exposure to faculty who are now busy taking up the slack, and considerable loss of the educational value of continuity in patient care.25 Perhaps most concerning is that there is as yet no evidence that any patient is better off or that quality has improved since imposition of work hour limits. Perhaps my main concern about work hour restrictions is that they have the potential to stifle initiative and drive in those who have the potential to be elite surgeons, and we know that we must find alternative ways to stimulate these characteristics now. We really need creative engagement with new ideas. We no longer live in the educational system that brought us to this point. We have accommodated to the mandate and we have devised a number of new systems of care that include moonlighting physicians, physician assistants, and nurse practitioners. We have devised intricate systems to monitor our compliance, although at the expense of concentration on modern surgical education. We have developed night float teams and wide cross-coverage, and we have designed elaborate and expensive computer-based programs to ensure timely information-sharing that will promote effective communication at the time of patient hand-offs.26 It has been necessary to develop team-based care, even though industrial studies have indicated that adding more people to a process increases the incidence of errors. In an analysis of why surgical faculty have been resistant to some of these changes, Kellogg and colleagues reported

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that we must encourage these changes, but to do so we will need to develop “a new template for professionalism,” a new value ethic, if you will.27 In fact, I seriously wonder if the new attitude we have had to develop will be as satisfying to the physician who entered the profession with different expectations. We clearly must continue to innovate and to make this system work, but as we introduce these changes, we must ensure that our professional value to promote the welfare of the patient first results in a system of education that produces surgeons with an attitude that embraces this ideal. One of the unintended consequences of the wellintended work hour limitation movement has been that it has reinforced certain contemporary societal attitudes that are antagonistic to the traditional values of medicine. Of course, I am referring to the perception that there is an emphasis on personal lifestyle first and care of the patient second. But it would be unfair to be critical without acknowledging some of the possible reasons for this. In addition, potential solutions lie in an understanding of why young people have developed an emphasis on lifestyle and what they believe represents balance and quality of life. My life has been my work and the quality of that life has been based on the fact that I have had the freedom and opportunity to follow my dream, but it has not prevented me from having a wonderful family life that has been as gratifying to me as my surgical career. I obviously hope that the products of the current emphasis on personal lifestyle will not end up like Tolstoy’s autobiographical character, Ivan, in The Death of Ivan Illych, who only realized at the very end of his life that his focus on personal lifestyle pleasures had far less substance and gratification than relationships with and contributions to the lives of others, as exemplified by his nurse who cared for him in his last days and changed his thinking. I do not think for 1 minute that the young people of today are less idealistic or more selfish with their time than we were at their stage. I believe that they are reacting to current influences in medicine and society that leave them few alternatives. I will mention just a few, with some thoughts for correction so that the traditional values that are the source for all physician gratification can be preserved (Table 1). I previously mentioned that the three elements of our surgical educational system are our academic institutions, our faculty, and our students. All three of these things are heavily influenced by the world around us. First of all, our students and trainees have observed our medical schools and teaching hospitals transition from places where one-on-one teaching was the rule; where care of the indigent was promoted; where role models were accessible and basic clinical skills promoted, to technical

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Table 1. Possible Causes of the “Lifestyle Attitude” Burdensome debt loads Decreased reimbursement for general surgery Difficulty discerning values in medicine Academic centers focus on business Fewer faculty role models General surgeons are in short supply and work harder than in other fields The impending nursing shortage means more work for surgeons Our failure to accommodate women’s needs

behemoths that focused on huge research enterprises and accumulation of clinical revenues, where the atmosphere is less personalized, where educational responsibility is spread broadly, and where the ever-increasing quest for dollars has focused the resources generated less on education and more on building facilities and implementing very expensive information systems. Undoubtedly, most of these contrasting changes have had positive results, but the unintended consequence has been that the leadership of our institutions, and that includes us, has given the message that economic concerns trump most everything else. Although unintended, the example has been that the business of medicine is as good a value as the other traditional values we have held dear in the past. Our students are finding it increasingly difficult to discern the true values of the profession, and it is not their fault. We must also ask ourselves whether we as a group have been ideal role models for our surgical residents. Have we, as faculty and teachers, joined in embracing the business of medicine, although necessary to some extent, to an excess where the example we provide to our trainees confuses them about what is really worthwhile? Are our lifestyles consistent with our traditional values? To what extent is our behavior and the values our behavior convey conducive to what we know is right? Could we change this generation’s emphasis on personal lifestyle by showing them a better way? It is only by engaging young people and demonstrating to them that their ultimate gratification with a life in surgery will come from their contribution to the lives of others, as Ivan Illych learned. I do not believe that the current emphasis on lifestyle and a shortage of individuals aspiring to a surgical career, particularly in general surgery, are based on avoidance of hard work or selfishness. I encounter medical students and residents every day, and I observe that they are more idealistic than ever and that they are brighter and more capable and industrious than we were. I believe that it is circumstances surrounding and influencing their lives that have forced them in this direction and, in addition, I believe that there are things that we can do to change this. I have already mentioned the changes in our academic institutions and how we appear as role models with some thoughts about

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change. These are issues that have undoubtedly influenced young people, with some possible suggestions for transformation. As one might expect, the majority of these considerations have considerable economic implications, but I believe that they are vitally important. I believe that the reason many students are selecting so-called “lifestyle specialties,” characterized by shift work, is because these fields are relatively protected in terms of reimbursement under Medicare and other insurance reimbursement. This is primarily because of enormous student debt, now averaging close to $200,000 and rising, a truly insidious influence. We must use every bit of our influence to convince our academic institutions, our government, and private philanthropy that tuition support for medical students is worthwhile so they can have a free choice of career. I do not think that we can do anything until we solve that issue. Currently, no one is taking responsibility for this and it is up to us. Again because of economic concerns, many students are not choosing a career in general surgery because they perceive that a career in a limited surgical specialty will provide them with a more secure income and allow them to satisfy their debts. Their perception is correct because this is clearly the current pattern of surgical reimbursement, and the students are bright enough to realize this. So, more than half of our general surgery graduates go on into various surgical specialties, almost in proportion to reimbursement trends. Yet we know that the future surgical workforce trends indicate that the greatest need will be in general surgery, based on the expected disease profile of an aging population. It is clear that one of our greatest deficiencies has been our failure to match our educational product to the needs of our health care system. We must do everything we can to make general surgery attractive and to influence both government and our academic health centers to provide incentives to those who are willing to entertain a career in surgery. This also means that we will have to do everything we can to influence equitable compensation for general surgeons, proportional to their value to society. If dermatologists, radiologists, and others continue to be reimbursed at a rate two to three times that of general surgeons, it will not be surprising that our students will avoid general surgery when they have such a debt burden. We must alleviate both student debt and inequitable compensation if change is to occur. The workload of surgeons has been shown to exceed almost all other branches of medicine, and it is common knowledge that there is an impending shortage of general surgeons, so why would anyone choose general surgery in an environment of noncompetitive compensation? We

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Table 2. Additions to the Surgical Curriculum Economics of healthcare and health care systems Principles of quality and safety How to achieve patient satisfaction Organizational models of healthcare Management tools Outcomes research

must do everything in our power to change this, not for us but for the next generation. There might also be some things we can do to make surgical education more attractive to aspiring students by offering things that appeal to the ideals of our current students. I think we have done a good job in modernizing the technologic aspects of our surgical residencies with the introduction of modern information technology, simulation centers, minimally invasive surgery, robotics, and the new science. What we need to add are educational modules that deal with understanding how to handle the economics of health care and health care systems, principles of quality and patient safety, how to achieve true patient satisfaction by satisfying traditional values, and being conversant with organizational health care models so that they can take appropriate leadership positions in the future (Table 2). If we can provide them with the tools of modern management, they can then see that they can influence their future lives in surgery rather than believing that their situation is hopeless and that they must accept the status quo. As teachers, we must be conversant with all new health care proposals and we must make that part of our surgical curricula, being careful to analyze new theories from the standpoint of how they fit our traditional values in medicine. A good example of this is Porter and Teisberg’s book, Redefining Health Care. Creating Value-Based Competition on Results.28 If our residents and we are to engage in constructive ideas such as this, we will need to provide education in this area and patient care considerations so that trainees will understand society’s demand that we stress value in what we provide. We have not emphasized health economics and its implications before now, but certainly the time has come. This will certainly appeal to prospective trainees. Another challenge that relates to the realization that surgeons work harder than others relates to the fact that we have an impending shortage in the nursing workforce. Peter Buerhaus and his colleagues at the Vanderbilt School of Nursing have done extensive studies on this subject and project a marked shortage of qualified nurses by the year 2025, which will intersect with an unprecedented demand for service, with the expected effect being a marked increase in cost and a decrease in quality, safety, and access to care.29 By 2025, the population of the United States is expected to rise to 350,000,000, with one-third of these children. Sur-

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geons are particularly dependent on nurses, and we must be part of the solution and do everything we possibly can to encourage young people to aspire to a career in nursing. The impending shortage of nurses is a disincentive for young people to go into surgery. In Alfred Blalock’s 1949 Presidential Address to this association, he discussed problems in the training of the surgeon.30 He had inherited Halsted’s mantel and he endorsed Halsted’s observation about the lives of his trainees, “the so-called sacrifices that our young men of today are willing to, nay, most eager, to make to obtain training seems even to them not only desirable but absolutely essential for the success of a high order.” Blalock added to that tradition by encouraging within his residency a university atmosphere within the hospital by emphasizing not just graduated responsibility but serious science. The problems Blalock identified were inadequate compensation for residents, a marked increase in the cost of hospital care resulting in the curtailment of teaching beds, and a changing pattern of practice in which faculty were obligated to seek private fees, resulting in a decreased emphasis on student and resident education. Although Blalock was unable to offer solutions to any of his concerns, he must be credited with the earliest warning related to our current situation. Another way we might be able to make our surgery programs more attractive is to offer opportunities in global medicine, particularly in developing countries, that bring us not only an opportunity to provide additional venues for clinical experience, but also to reinforce values, emphasize societal needs, and provide an example for compassion that only volunteer activities can provide. Having just recently returned from Kenya, where I worked in a district hospital that serves a local population burdened with AIDS and an ethnic refugee camp, has taught me that there are great lessons to be learned by working in such an environment. Perhaps there is no more important challenge for us to engage in surgical education than for us to show women that we want them in surgery, and that we will adapt our system to their needs. Currently half of the medical students in the United States are women and too few of them are going into surgery. Although the trends have been encouraging of late, much more must be done if we are to alleviate future workforce shortages in surgery. We must keep in mind that women have considerations of life, not just lifestyle, and not just because they also have terrible debt burdens. Until now, women have more or less been forced to make a choice between a surgical career and the opportunity to have a family and all that includes. I do not believe that they should be forced to make such a choice because there are potential solutions. I would emphasize that it is important for us to strive for solutions because we

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Table 3. Incentives for Women in Surgery Time off in residency to have children Part-time work possibilities in the child-rearing years Dependable access to child care during residency and early practice years More residents and faculty of same gender Shared practice models, flexible hours Information from Snyder RA, Bills JL, Phillips SE, et al. Specific interventions to increase women’s interest in surgery. J Am Coll Surg 2008;207: 942⫺947.

need more women in surgery and we surely will have them. One of our Vanderbilt surgical residents, Rebecca Snyder, surveyed a large cohort of medical students in the United States about the sorts of things that might encourage them to consider a surgical career, and the results provide guidance31 (Table 3). In addition, it turned out that a desire for enough time to attend to family duties was not mutually exclusive with their idealism and desire to uphold the values of medicine. The main determinants for these young women were time off in residency to have children, the prospect of parttime work or job-sharing during the child-rearing years, dependable access to childcare facilities both during residency and the early practice years, and similar considerations. It might be that some of these measures to encourage women to embrace a career in general surgery might require some lengthening of training, but they accept that, and it might be that more surgeons will be needed to accomplish the same amount of work if the part-time model becomes prevalent. So what? It should also be pointed out that some men have also expressed a desire for part-time work in surgery, just fewer than women. We must advocate for all of these possibilities if we are to attract sufficient numbers of women to our residencies in general surgery. Along with lobbying to improve the status of general surgery, we must exert vigorous efforts to lift the Medicare GME cap, so that there are fewer barriers to increasing the number of residency positions, particularly in the field of general surgery (Table 4). It must be considered as if it is primary care, which in many ways it truly is. We must also urge our Residency Review Committee for Surgery to be more flexible so that new experimental models of surgical education can be developed. We cannot afford to stifle creativity in this arena. Unless we improve our models of surgical education, I worry that fewer elite surgeons will be produced. One must ask, is it possible, in the present framework, to produce surgeons capable of replacing the entire thoracic and abdominal aorta, or of performing extremely complicated reconstructive procedures or multiorgan transplants? A rule of life for the surgeon has always been considered personal responsibility. How do we best teach that? Without

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Table 4. Organizational Challenges Lift the GME cap now frozen at 1996 levels Have the RRC encourage new experimental models in education Focus on personal responsibility in team-based care RRC, Residency Review Committee for Surgery.

question, example and mentorship are the most important. It is up to us to demonstrate those qualities of professional behavior and interpersonal relationships that characterize the responsible physician. Another element of surgical education that must be strengthened is familiarizing trainees with outcomes research and evidence-based medicine because that is a modern language they will all need to speak. In addition, we will need to insist that under the concept of team-based care, necessitated by the 80-hour work week restrictions, residents know everything there is to know about their patients. How often in teaching conferences or morbidity and mortality analyses, do we hear residents say, “I was not there when the patient came in the other night” or “I was not at the operation and am not sure of the exact pathology”? Expressed in other terms, can the patient⫺team relationship provide the same humanitas and caritas as the patient⫺physician relationship? I think it is possible, but it will require constant reinforcement. One can certainly argue that the complicated nature of patient care today that involves serious illness requires a team, but shouldn’t someone be in charge and shouldn’t the care be personalized? Patients have always valued personalized care because they want someone they can depend on to care for them. This is vividly shown in Francisco Goya’s painting of himself and his physician Dr Arrieta, who cared for him during a serious acute illness and who stayed by his side until he was well. Goya painted this in gratitude to Dr Arrieta, and it is illustrative of what patients want in a physician. We have other challenges ahead in medicine that will have an influence on surgical education of the future, such as how to ensure that we provide the best quality care, how to provide care to all regardless of ability to pay, how to make our profession more diverse, how to extend our expertise globally, how to expand and translate our science into treatment with measurable outcomes, and how to reaffirm our ethical and professional values in an environment where business interests distract us and preempt our tradition of service to individual patients before ourselves (Table 5). Regardless, I am confident that we have the intelligence and the spine to face these challenges and to make American surgical education relevant to what society needs and the outcomes required. I have a sense of optimism because I know we have a sense of place in which we understand our cultural identity and meaning. I know that we understand that we have a moral responsibility to bring

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Table 5. Other Challenges How to insure we provide the best quality care How to measure competence How to provide care to all regardless of ability to pay How to make our profession more diverse How to extend our expertise globally How to expand and translate our science into treatment with measurable outcomes How to reaffirm our professional values and our tradition of service

the unique resources of our intellectual community to bear on these pressing issues. The role of the Southern Surgical Association in the surgical and educational history of this country is quite clear, and particularly the efforts of some individuals. It is our responsibility to follow our conscience and advocate for change. Many of us are educators; some are innovators; and some are or will be policy makers in strengthening surgical education as it evolves according to our traditional values. It will take everyone’s efforts and I urge this association to use its influence to advocate for what we know is right.

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