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Surgical education in the new millennium: the university perspective
Surg Clin N Am 84 (2004) 1425–1439
Surgical education in the new millennium: the university perspective Larry R. Kaiser, MD*, James L. Mullen, MD Department of Surgery, University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA 19104, USA
This is a particularly auspicious time to have the opportunity to comment on surgical education. A number of forces have combined to mandate a major paradigm shift in the way we educate surgical residents, and the final word is not yet in, to say the least. At the same time that we have begun to systematically look at ways of insuring patient safety, we have been mandated to cut resident work hours to 80 hours per week. This has forced us to develop alternative approaches to patient care that do not involve resident participation at various times. The widespread use of what we call ‘‘clinical surgical specialists,’’ nonphysician health care providers, has introduced an entirely new set of issues with which we as surgical educators must deal. The restriction in resident work hours has caused us to focus very specifically on the balance, or lack thereof, between service and education. Whereas in the past the education often took a back seat to the service role of the resident, the reduced hours residents are allowed to work today have given us the opportunity to focus on the education component, where our efforts should have been directed all along. The changing demographics of students entering medical school has also mandated a change in the way we think about surgical education. Now that medical school classes are comprised of at least 50% women, a group that classically has not flocked to surgery as a profession, we are under increasing pressure to make the specialty more attractive, starting with the education component. Students entering medical school today have a different set of values than students who entered 20 years ago. There is more of a global perspective, and an increasing awareness of service, as opposed to the desire to generate a large income. Students in medical school today cite lifestyle issues as the single most important influence in choosing a specialty. The next generation of * Corresponding author. E-mail address: [email protected] (L.R. Kaiser). 0039-6109/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.suc.2004.06.012 surgical.theclinics.com
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surgeons will come into the specialty and remake the lifestyle, just as we are remaking the residency now. Reimbursement for surgical services has continued in a steady decline over the past 15 years, while the cost of doing business, particularly the cost of malpractice insurances, has continued to increase or even skyrocket in some states, such as Pennsylvania. Those of us who have been educated in university residency programs and continue in faculty positions at university programs develop a somewhat skewed view of the world of surgery, and periodically need to remind ourselves that ours is not the only world. Less than one fourth of surgical manpower resides in academic medical centers, and thus the majority of surgical care, whether we readily admit it or not, is delivered outside of such centers. The challenge for the surgical educator, whether in an academic medical center or in a freestanding community-based program, remains how to most effectively educate the surgeons of tomorrow so that American surgical care remains the finest in the world. Major change that will affect the profession of surgery for many years to come has occurred, and continues to occur at multiple levels. In fact, the changes occurring now may be the most sweeping to occur since the advent of the Halstedian residency system. As we have alluded to above, these changes begin with the surgery applicant pool, and extend through the radical change that is underway in the recertification process now referred to as ‘‘maintenance of certification.’’ Change in applicant pool Applications to medical school peaked in the mid-1970s, and then declined for a number of years before again beginning to increase. A career in medicine, unfortunately, may no longer be attracting the best and the brightest students. Most students find themselves in debt upon completion of their medical education, often owing significantly more than $100,000. Faced with a minimum 5-year surgery residency and, for many, at least 1 or 2 years more of fellowship, not to mention time spent in the research laboratory for those interested in academic careers, it is easy to see why many are turned off by surgery as a career. Yet in a recent survey, lifestyle issues assumed much greater importance than length of time spent in training [1]. The medical student’s perception of the surgeon’s lifestyle is not a favorable one, especially among women, who remain underrepresented in surgery, particularly in the senior ranks of academic surgery. Attracting women into surgery is one of the greatest challenges facing our specialty , especially in the academic world, because it is even more difficult to convince a woman to pursue a career in academic surgery, mainly because of the constraints imposed by the promotion system. Until recently, there was little flexibility in an academic career model, especially in institutions that retain an ‘‘up or out’’ promotion process. Despite extensions of the probationary period granted for childbirth, the difficulty a woman has in amassing a significant body of scholarly work while establishing a clinical
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practice and raising a family markedly compromises the likelihood of promotion. The flexibility inherent in a private practice makes it significantly more attractive to the woman surgeon. Creating job descriptions for women in academic surgery in which priorities can be aligned appropriately, while allowing for progress toward promotion, remains one of the great challenges to be met as we move forward in the new millennium. We can no longer afford to ignore women in academic surgery, nor should we expect women to be pigeonholed into certain specialties that are more ‘‘suitable’’ for raising a family. Women should be able to pursue the specialty of their choice, while retaining the assurance that issues regarding lifestyle will assume the same level of importance as that accorded to their professional life. This is particularly important if a career in academic surgery is to be at all attractive to women finishing medical school in the twenty-first century. The challenge for those of us in leadership roles in academic surgery is to build enough flexibility into the academic model to make it feasible for both men and women to combine family life with a successful and satisfying academic career. It is no longer acceptable to many people to have all of the sacrifices come from the family side of their lives, and in the future, there will have to be some flexibility on the professional side. Krizek has questioned whether surgery is an impairing profession, and points out a number of elements inherent in our specialty—and specifically in the way we educate those interested in our specialty—that contribute to the development of impairment in the broadest sense [2]. In order to achieve a more acceptable balance between profession and life outside of the profession, changes must begin at the residency level. Concessions must be made to take lifestyle issues into account. Programs in which research education is built into the residency experience for 1 or 2 years do offer the possibility, for instance, of scheduling a pregnancy during that nonclinical time, but many programs do not have such nonclinical time built in. Creative solutions need to be devised to cover maternity leave time for women during surgical residency. As we fully incorporate more nurse practitioners and physician’s assistants into our clinical programs, to cover the service function formerly performed by house staff before work-hour limitations, providing coverage for a resident on maternity leave should become fairly routine. Changing regulatory pressures The institution of work rules has forever changed the face of the surgical residency, and we are just beginning to see how those changes will look. Many questions remain and, in the authors’ estimation, it will take at least 5 years of living with the new rules to draw any conclusions, good or bad, as to the effect of these changes. By this we mean the effect on the end product, the fully trained surgeon. Even this concept is changing. We are not truly now ‘‘training’ surgeons, nor for that matter have we ever done so. One
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would like to think that we educate surgeons, and the work-hour rules have caused us to rethink this issue as well. Training was probably a more accurate term previously, because many programs followed an apprenticetype model, in which trainees put in long hours, mostly performing service work and gathering in what education came their way. In some institutions, the duties of the house staff included transporting patients, drawing blood, obtaining test results, and other service functions that could easily have been performed by nonphysician personnel. These tasks, as well as taking inhouse call, were all part of the price paid, especially in the junior years, for the benefits that would come during the later years of the residency program, the operative cases. Time in the operating room (OR) increased as one progressed through the years of the residency. In many programs, the time spent in the OR during the first year of residency was minimal, and decreased further with the introduction of table-mounted, self-retaining retractors that obviated the need for a junior person to be present. The service requirements outside of the OR took up most of the junior resident’s time, while contributing little to the overall education, though we were loathe to admit it at the time. It was truly the price to be paid to get to the next level. House staff, particularly junior residents, represented to the hospital a very inexpensive labor force, carrying out tasks that would have cost significantly more if paraprofessionals were performing them. If we assume that the cost of a nurse practitioner is $100,000 per year and recognize that they work half as many hours as a resident (40 hours instead of 80 hours) and cover half as many patients (10–12 versus 20–25), then the value of a single resident is approximately $400,000 per year, not an insignificant amount. The work-hour rules have forced surgical educators to become just that—educators. The balance between service and education clearly has changed, and because of the limitation of work hours, surgical program directors have been forced to look closely at the value of every hour spent by residents in the hospital. The authors believe that this is an unintended, though clearly beneficial, consequence of the work-hour rules, and that the framers of these rules had no idea what they were creating. This is not to say that adapting to the limitation of work hours has been or will be easy. There is no convincing evidence to date that limiting work hours for residents will improve patient safety, but the evidence is beginning to accumulate that these restrictions will significantly improve resident education. To provide a surgical education, we must have a curriculum, something that did not previously exist in any formalized fashion under the apprentice model. The curriculum must be well defined, with learning objectives articulated for each rotation and for each level of resident. Obviously, the objectives for a first-year resident on a gastrointestinal surgical service will be different than those for the chief resident on the service. Resident evaluations should be based on these objectives, as should the evaluation of the faculty by the residents. Objectives must be clearly stated, and ideally should be developed jointly by the residents and the
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faculty. Formalizing a curriculum is the only hope of achieving a balanced and complete surgical education, in which the amount of service time, though not zero, must be minimized. Formerly, most residents got the education piece mostly as a function of being present in the hospital for so many hours. It just rubbed off, as it were. And this worked fine for most, mainly because we never looked critically at the process. The Residency Review Committee (RRC) reviewed programs, and the American Board of Surgery (ABS) required certain numbers and types of cases, but no formal process existed to review the education received by the resident. Successful completion of the certifying and qualifying examination of the ABS by a resident finishing an RRC-approved program meant nothing more than that the individual had fulfilled a minimum set of requirements and had passed a written and oral examination. The ABS, or any certifying board for that matter, failed to address the issue of competence or quality of the education, and still does not. None of the qualifying or certifying examinations are designed to discriminate the well-qualified from the less wellqualified individual. To optimally educate residents in fewer hours, the service role formerly performed by them must be assumed by others, usually nurse practitioners and physician assistants, but some are still convinced that the length of the residency will need to be increased as well to make up for these lost hours. The authors remain convinced that the emphasis placed on an objectivebased curriculum and the increased efficiencies inherent in a well thoughtout educational experience will more than make up for the lost hours, most of which formerly were spent nonproductively. This will require, however, some innovations in surgical education, many of which are already being employed. The use of simulators and inanimate training models before coming to the OR and as an adjunct to developing advanced skills will optimize the educational experience in the OR. For example, once laparoscopic skills have been acquired in the inanimate laboratory, not only will the OR experience be more meaningful for the resident, but also safer for the patient: anesthesia time will be shorter and errors in technique fewer. The use of computer simulation, especially with three-dimensional viewing and tactile feedback, will allow the resident to practice complex procedures multiple times before attempting to perform them in the OR. At the completion of a surgery program, the finishing resident may have had fewer cases in number, but the educational experience garnered from each case should be significantly greater. This should cause us to rethink our emphasis on numbers and concentrate more on the quality of the educational experience. The issue of patient safety has assumed greater importance, in the profession and certainly in the mind of the public, who have been deluged with well-publicized horror stories of surgical misadventures. The role of the surgical resident assumes great importance in reducing errors, and surgical programs must take this into account as the educational model changes. For
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optimal patient safety and error reduction, a climate must be created in which attention is directed not at placing blame but at looking at systems approaches to reducing error, not just within the residency program but within the institution as a whole. This involves creating a climate of mutual respect without fear of punitive actions against those who report errors. We as surgical educators need to instill early-on a collegial, team approach to patient care that involves nurses, nurse practitioners and physician assistants, hospitalists, and the patient and family. Thus the teaching of leadership skills should be a part of the curriculum, because team leading is not necessarily an acquired skill for all. Formal instruction, if only minimal, in team leading would go a long way toward creating a collegial environment in which everyone is working together for the good of the patient. A hostile environment in which the first impulse is to place blame will not succeed in improving patient safety. This type of collegial practice has not been part of the surgical residency and represents a new paradigm. This approach needs to be part of the fabric of the institution, so that residents can begin to see surgical practice as a team effort. The team approach will be particularly important as we go forward, because the surgeon can no longer hold himself apart from the other team members. This concept needs to be introduced very early in the resident’s education. The design of the collaborative practice model between residents and midlevel providers is crucial to guard against actually creating more patient safety issues by increasing the dependence on handoffs and communication. Volpp and Grande cited eight problems faced by residents that, if solved, would considerably improve patient safety in his view from a resident’s perspective [3]. The suggested solutions generally fall into three categories: use of technology, improvements in the work environment, and change in the academic culture. Many of these already are in place, including computerized order entry and work-hour limitations, but others, such as computerized sign-out, are less prevalent. Volpp and Grande also stressed the idea of a team approach, and the creation of a collegial culture that rewards the reporting of adverse events. Effort should be directed toward defining systems problems that, if corrected, will reduce or eliminate errors. Residents should be a major part of all efforts in error reduction, and must be key members of the team. To do this, residents cannot be subjected to an increased workload while on duty in order to make up for fewer hours worked overall. Changing educational goals Coinciding with changes being made in the mechanics of the education of the surgical resident is a fundamental change in thinking regarding the specialty of surgery in general. The ABS is currently struggling with the notion of a definition of general surgery, and within that context is trying to structure surgical education to best meet the needs of that specialty and the
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various subspecialties. It is likely that within the next 10 years we will see a restructuring of the surgical residency that will allow those interested in general surgery to pursue that specialty in depth, while allowing those interested in the subspecialties to branch off earlier. There has been much discussion at the ABS level of a core curriculum in surgery that all surgical specialties would have in common, and that would consist of 2 or perhaps 3 years, and the termination of this core would be the jumping-off point for the subspecialties. An examination in basic surgery would be the culmination of the core curriculum to be completed by all trainees, no matter what the specialty. Likely this will assess basic knowledge in surgical principles and surgical-related basic science common to all surgical disciplines. Those interested in general surgery would continue on in an as-yet-to-be-named program in ‘‘advanced general surgery’’ or some other apt title. This would distinguish these individuals as specialists in their own right, but is greatly dependent on how the specialty becomes defined. Likely there will be several tracks, including one in rural surgery, for which the curriculum would include some additional subspecialty education such as gynecology, urology, and perhaps thoracic surgery. Currently there is no timetable articulated for these changes to occur, and for that matter, there has been no official statement that they will occur. The report of the blue ribbon panel appointed by Haile Debas, MD, during his term as president of the American Surgical Association, was presented at the April 2004 meeting of the association, and publication of the recommendations of this group should appear soon. Much discussion and debate remains before such radical change occurs in surgery, but there is a widespread belief that the time has come. The core curriculum in surgery has been discussed for a number of years, but there is a sense now that the time has come, and the report of the blue ribbon panel should serve as a catalyst to move this forward. The funding of graduate medical education will continue to be a challenge. In academic centers, we have an advantage over community hospitals, because departments may accumulate endowment income, with the interest being used to fund at least partial salary support for certain faculty members. This includes the establishment of endowed professorships as well as restricted or unrestricted accounts. Currently, much of the time given to education is unfunded time, and the time this takes from clinical work must somehow be compensated. At the University of Pennsylvania, the department of surgery is fortunate to have a research endowment that was begun in 1877, when D. Hayes Agnew was installed as the first John Rhea Barton Professor of Surgery, the first endowed chair of surgery in the country. Funds have been added to this endowment over the years, and in addition to a number of individual restricted and unrestricted funds, we now have 10 endowed professorships. The use of endowment funds can significantly add to the teaching program, especially if used to support the protected time of junior faculty to aid in faculty development. Community
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hospitals essentially rely completely on volunteer faculty, who recognize that the time spent teaching is uncompensated and is done without the expectation of anything in return expect personal satisfaction. Any type of faculty development in a community hospital has to rely on the individual faculty member. Part of the mission of an academic department of surgery should be to raise money for the endowment, so that teaching and faculty development can continue to be supported. One can envision the change toward a core curriculum occurring over the next 10 years, with a phase-in beginning perhaps within 5 years. This timetable, however, is merely speculation, because there are so many stakeholders who must buy into such a curriculum before its initiation. Already major changes have occurred. As of July 2003, those entering a cardiothoracic training program no longer are required to be certified by the ABS before sitting for the American Board of Thoracic Surgery qualifying examination. This marks a radical departure; however, those entering a cardiothoracic residency still must complete a full RRC-approved general surgery residency. Similarly, the ABS has approved a fast track for both pediatric surgery and vascular surgery that allows for dual board certification in a shortened time frame for those who combine a program in the same institution. Neither vascular surgery nor pediatric surgery has embraced this proposal. Leadership in vascular surgery has been working toward a separate board for a number of years, an effort that has a significant chance of succeeding, and one that has been caused by the major change in the specialty that has occurred over the last decade because of the rise of endovascular procedures. All of these changes will have major implications on the education within a general surgery residency. The creation of a core curriculum based on a broad-based agreement among the various subspecialties may eliminate some of the current problems that arise with slotting of residents in accord with the various wishes of subspecialty program directors. The major emphasis of any core curriculum has to be education, with the service role taking a subservient position. The creation of a core curriculum may also alleviate some of the concern about the loss of ‘‘index’’ cases, which become diluted when everyone competes for them at the senior resident level. With subspecialty tracking, the index cases in general surgery will be covered by those residents pursuing advanced general surgery, thus also addressing the concerns about the adequacy of the educational experience with limited resident work hours. With the move toward earlier delineation of specialization, a number of other concerns arise. Until recently, the surgeon, as the captain of the ship, controlled the care of the patient from admission to discharge, including time in the intensive care unit, if required. The role of the intensivist or critical care specialist has changed some of this, with the changes potentially beginning at the residency level. Most programs expose residents to the intensive care unit (ICU) environment as part of a critical care rotation in
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which they come under the supervision of critical care attending physicians, some of whom are surgeons and some of whom are not. In many settings, the care of the intensive care patient has shifted from the primary surgeon to the intensivist, with the surgeon playing a much more passive role, and in some cases not permitted to write orders. Models of intensive care practice vary from an open model, in which the attending surgeon remains in charge of the patient’s care, with input and assistance from the critical care team, to a closed model, in which the patient is managed solely by the intensive care specialists. In between is a semiclosed model in which the patient is managed primarily by the critical care team, but the attending surgeon remains able to write orders and control the care of the patient. Outside organizations have weighed in on this issue, with the leapfrog group using management of patients in the intensive care setting by intensivists as one of its primary criteria for quality measurement [4]. What are the implications for the resident with the intensivist model? First and foremost, they learn that the care of critically ill patients is better managed by those who do it on a fulltime basis, with resultant improvement in survival and shorter length of ICU stays [5]. The concept of the busy surgeon managing the care of a critically ill patient while spending the day in the OR is no longer viable with the current level of sophistication that exists for the care of the ICU patient. With management decisions often made on a minute-to-minute basis, it is impossible for these patients to be managed from afar. That being said, it is important to realize there is no turning back from this. The model in which ICU patients are managed by intensivists may result in surgical residents lacking the knowledge to manage these patients, and thus they will develop a reliance on this model moving forward, whether they opt for a community or a university-based practice [6]. Surgeons interested in managing critically ill patients will of necessity need to complete a surgical critical care fellowship, and perhaps more individuals at the resident level should be encouraged to do this; otherwise, the care of the critically ill postoperative patients will fall solely to our nonsurgical intensivist colleagues. Is the reliance on the intensivist model necessarily bad? Not necessarily, though it represents a major departure from the way that surgeons have become accustomed to working; however, the changes taking place at the resident level likely will dictate future practice. Taking this argument to its logical conclusion, one must ask if surgeons might become well rested, poorly educated technicians if the care of ICU patients is relinquished and other providers, such as hospitalists, assume the care of postoperative patients. Our early experience with a collaborative resident–midlevel provider model has raised serious concerns that the routine pre- and postoperative care is being shifted to the midlevel providers, and the resident is being relegated to the role of technical student in the OR. We have not seen the full impact of this trend, because currently the collaborative model is only in play during regular daytime work hours, and the residents assume full care in the other 100 or so hours
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per week. This is a concern that must be addressed at the residency level, by making sure that the care of the surgical patient is not lost from the curriculum. Residents must be exposed on a regular basis to the outpatient aspects of surgery by participating in office hours, both to gain the ability to assess patients with surgical problems and make a decision regarding treatment, and to gain some perspective on the follow-up of postoperative patients. There is no question that the mechanics of the care of the surgical inpatient are changing and will be changed forever, as the current generation of residents completes their education. The education of the surgeon is not the only end point in the process. The most significant end point is the delivery of outstanding, safe care to the surgical patient, no matter how the model evolves. Surgical education must be based on this precept, with the recognition that change is inevitable. Concerns about whether in a new model of surgical education we will be able to instill in the resident a sense of responsibility and ownership for the care of the patient are valid, and need to be addressed. In the past, this sense was inculcated by spending countless hours, including nights, in the hospital, without any real sense as to the value of those hours. There is every reason to expect that a collaborative-care model should result in improved care for the patient, though this change will not come easily for surgeons not educated in this model. Our residency system has promoted residents on the basis of time served, and the complexity of the cases performed by an individual resident is usually tied to the seniority of the resident; that is, a clinical fourth-year resident will have more responsibility both within and outside of the OR than a second-year resident. Rarely is a resident held back in a surgical program, even if significant deficiencies have been noted. We need to move toward a system where advancement in the residency program and completion of the program is tied to demonstrated competence, not just the completion of a specified number of years. This is in accord with the six core competencies put forth by the Accreditation Council for Graduate Medical Education (ACGME) and mandated to be addressed beginning with the residency program. These core competencies also form the basis and guidelines for lifelong learning. Residents, and for that matter, medical students, will need to be assessed on the basis of these core competencies. It is naive to assume that all individuals entering a surgical residency will be competent to practice surgery after 5 clinical years. Some may require more than 5 years, and it is incumbent upon us to recognize these individuals, and to predicate advancement on the development of certain skills, not just on time served. To optimally evaluate resident performance, the objectives for each rotation at each level need to be met before advancement can occur. Not all residents will develop surgical skills at the same rate, and this fact has to be incorporated into our thinking about residency education. With the focus on education, we should be able to better individualize a resident’s experience than we have done previously.
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Change in the public’s expectations What is reasonable for members of the public to expect when they enter a teaching hospital? It is assumed that patients coming to a university hospital recognize that residents and fellows will be involved in their care. There is a clear lack of understanding as to the extent of the involvement of these individuals in their care, but it is safe to assume that most people expect their care to be provided by their attending surgeon. Where then does the resident fit into this scenario? How do we handle the patient who insists that the attending surgeon perform the operation? These are sensitive issues and are not unique to the university setting, but are shared with community teaching hospitals as well. How do we continue to try to answer the public’s demand for perfection while providing an education for our successors? Paradoxically, the limitation of residents’ work hours may be an advantage, because their education must be the paramount concern during the hours residents are in the hospital, allowing much of the mundane aspects of care to be attended to by other providers who provide consistency and specialized expertise. The nurse practitioners assigned to a service are a constant; they do not rotate on a monthly or bimonthly basis, and therefore they develop in-depth knowledge of the needs of the particular type of patients under their purview. This can only work toward the patient’s advantage, and experience has shown that patients defer to these individuals who they can communicate with, both in the preoperative and postdischarge settings. Residents need to be integrated into this wellfunctioning system for the sole purpose of coming away with the significant elements of caring for the surgical patient. Much of the residents’ time will be spent in the operating room, where, not being sleep-deprived from a night spent on call, they can pay more attention to the details of the operative procedures. It is reasonable to expect that residents will come to the operating room better prepared for the cases to be performed, having reviewing the records and imaging studies as well as read the relevant text material and pertinent journal articles. Additionally, they might have a chance to do a simulated version of the operation, especially if they are doing a procedure for the first time. There is every reason to expect that the teaching in the operating room can become a more valuable experience with the additional time allotted for preparation. With improved preparation, it is not unreasonable to expect improved concentration, especially in the well-rested resident, and thus a minimization of errors in technique. We must incorporate surgical trainers and simulators to complement the didactic piece, so that the time in the operating room can be used to maximal advantage. Not all of us are great teachers, and residency programs must look closely at this and assign house staff to those who not only are willing to teach, but are willing to work to improve their teaching skills. It will become incumbent upon all of us to improve our skills, so as to maximize use of the residents’ limited time in the most efficient fashion.
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Unless we want to extend the duration of the surgical residency, we must become more efficient in our methods of teaching. This should be facilitated by residents coming to the operating room better prepared for the case to be performed. We need to work with faculty members to enhance their ability to teach in the operating room. Those who already have developed these skills can and should be called upon to work with their faculty colleagues who are not as effective in intraoperative teaching. For instance, when new faculty members are hired directly out of residency, no effort is made to evaluate their teaching ability in the operating room, nor is anyone routinely assigned to work with them to develop these skills. This is an area that invites significant improvement, but we have to be open to such an idea and, up until now, we have not been. Patients expect, appropriately, that they will receive the best possible care. Resident participation should enhance their care, especially for the patient who is critically ill or has a serious medical problem, but this may not always be the case. Patients should be informed that residents will be participating in their care, including their intraoperative care, but they should be reassured that the surgeon will be present for the key portion of the operative procedure. In comparing surgical outcomes between teaching and nonteaching hospitals in the Veterans Administration (VA) hospitals, Khuri and colleagues found that the majority of complex and highrisk cases were done in teaching hospitals within the system, and noted 30day, risk-adjusted mortality rates comparable with those of the nonteaching hospitals [7]. Risk-adjusted, 30-day morbidity rates were higher in some specialties and operations than in the nonteaching setting, however, reflecting either the weak predictive validity of the risk-adjustment models or suboptimal processes and structures of care unique to teaching hospitals. Conversely, Baskett and colleagues demonstrated that operative morbidity and mortality in coronary artery surgery and aortic valve replacement was similar for residents and staff in a single institution in which the residents performed almost 600 cases [8]. Residents performed the cases under direct staff supervision. Being part of a teaching environment implies that care will be managed by a team, not by just one individual, and ideally more attention will be paid to each patient, but this needs to be looked at more closely. It has been recognized by many that, for certain cases, high-volume surgeons have better outcomes than low-volume surgeons [9]. The catch here is that all surgeons have to start as low-volume surgeons. The learning curve associated with certain specialties and certain procedures is well recognized. Working in high-volume hospitals, especially with surgical residents, likely attenuates these learning curves. Changing environmental pressures As we enter this new era of surgical education, a number of pressures exerted from outside the residency program will influence the way we conduct business. Residents generally enter surgical residency with significant debt
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from medical school, often reaching levels greater than $100,000. They enter into a residency program that lasts a minimum of 5 years, going up to 7 or 8 years, and that may include an additional fellowship. The opportunity to moonlight during the residency, particularly during the research years, allows for some of this debt to be paid down. During the clinical years, the entire focus of the resident needs to be on the clinical education; thus moonlighting during this time should be prohibited. It remains to be seen what effect the limitation of resident work hours will have on the case numbers of residents completing surgical programs. There is very little, if any, enthusiasm for lengthening the residency program to make up for the potential lost case volume. Despite declining reimbursements, many individuals look forward to the completion of their residency and the beginning of a practice to relieve them of their debt obligation. Herein lies a dichotomy between an academic program and a community-based program. Most, if not all, residents attracted to a community-based program will go on to the private practice of surgery, often general surgery. These programs mostly do not include any significant research experience, because it is not sought after by the type of individuals attracted to the program. Conversely, most university programs offer residents the opportunity to pursue 1 or 2 years of research, with the expectation that most will take advantage of that opportunity. The thought here is that many of these individuals will pursue careers in academic surgery, and that some will be able to go on to establish independent laboratories and obtain individual funding. If we are to continue to produce these surgeon-scientists, we must continue the mentoring process during the early years of an academic appointment, following the completion of the residency. We in surgery have not taken full advantage of the National Institutes of Health (NIH) K awards, the mentored clinical scientist program, whereas other specialties use these widely. The challenges faced by the young surgeon-scientist in trying to build a successful research career while at the same time building a clinical practice make the advice and counsel of a research mentor invaluable. Just having protected time to pursue research is a major challenge, both from the standpoint of getting started in the laboratory and in complying with federal requirements mandated by an NIH award. Without protected time, it is virtually impossible for a young surgeon to succeed in research, and the research will likely be given up fairly early because the clinical work is required to feed the family. If the research endeavor is not established early, it is more likely than not that it will not be successful. Surgeons are ideal at developing collaborative research ventures with colleagues from other disciplines, because the surgeon can bring unique questions to a research program and has ready access to tissue obtained from the operating room. Funding research training for surgical residents has always been challenging, but is likely to become more so as the NIH budget stabilizes following the major funding increases of the last 5 years. In most
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departments, there is not a sufficient excess of clinical dollars to fund resident research; support must be sought elsewhere and is not easy to find. Residents may apply for support through a number of professional organizations, including the American College of Surgeons and the Association for Academic Surgery, among numerous others. Application may also be made for individual National Research Service Awards. The successful academic department of surgery will set aside protected time for junior faculty interested in pursuing an investigative career, and will find the resources to allow most, if not all, residents to participate in surgical research during the residency. Introducing research training early in the surgical career is more likely to be associated with a successful research career later [10]. Academic departments will need to search for new sources of funding for surgical education as well. The development of corporate partnerships for funding pieces of the academic enterprise will remain important. For example, the funding of a laparoscopic fellow could potentially be supported by a maker of laparoscopic instruments, through an unrestricted educational grant. Chairs of academic departments need to spend a significant amount of time developing the types of relationships with corporate partners that lead to these funding opportunities. It is in developing these types of relationships that academic programs retain a major advantage over their community counterparts. Corporate partners have the resources to partner with an academic program or institution, and often see it as advantageous and validating. These educational partnerships can take many forms, and at the University of Pennsylvania we have benefited greatly from multiple partnerships with United States Surgical Corporation, Storz, Guidant, ComcastSpectacor, Getinge, Ethicon, and others that for many years have recognized a commitment to support surgical education, and have provided much needed resources. Summary It remains the province of academic departments of surgery to educate the future leaders of surgery. This is the single major factor that differentiates academic programs from community programs. This is not to say that academic programs are more important than community programs, only that their missions differ. Not everyone who completes surgical education in an academic program desires to become a surgical leader, but the very nature of our specialty makes all of us leaders in one way or another. Although we always recognize the collaborative nature of surgical practice, there is only one person in charge in the operating room during a surgical procedure. Thus all surgical programs produce leaders in one way or another. It is from the academic programs that the intellectual leaders of the next generation must emerge. In times of change, it becomes even more important to have leaders who are well prepared to face the new
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challenges that lie ahead. Our job as academic surgeons is to equip these leaders with the tools necessary to be successful.
References [1] Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290(9):1173–8. [2] Krizek TJ. Ethics and philosopy lecture: surgery . . . is it an impairing profession? J Am Coll Surg 2002;194:352–65. [3] Volpp KGM, Grande D. Residents suggestions for reducing errors in teaching hospitals. N Engl J Med 2003;348:851–5. [4] Manthous CA. Leapfrog and critical care: evidence- and reality-based intensive care for the 21st century. Am J Med 2004;116:188–93. [5] Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288(17):2151–62. [6] Barone JE, Tucker JB, Bull SM. The leapfrog initiative: a potential threat to surgical education. Curr Surg 2003;60(2):218–21. [7] Khuri SF, Najjar SF, Daley J, Krasnicka B, Hossain M, Henderson WG, et al. Comparison of surgical outcomes between teaching and nonteaching hospitals in the Department of Veterans Affairs. Ann Surg 2001;234:370–82. [8] Baskett RJF, Buth KJ, Legare J-F, Hassan A, Friesen CH, Hirsch GM. Is it safe to train residents to perform cardiac surgery? Ann Thorac Surg 2002;74:1043–9. [9] Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349(22):2117–27. [10] Thakur A, Thakur V, Fonkalsrud EW, Singh S, Buchmiller TL. The outcome of research training during surgical residency. J Surg Res 2000;90(1):10–2.
Surgical education in the new millennium: the university perspective Larry R. Kaiser, MD*, James L. Mullen, MD Department of Surgery, University of Pennsylvania, 3400 Spruce Street, 4 Silverstein, Philadelphia, PA 19104, USA
This is a particularly auspicious time to have the opportunity to comment on surgical education. A number of forces have combined to mandate a major paradigm shift in the way we educate surgical residents, and the final word is not yet in, to say the least. At the same time that we have begun to systematically look at ways of insuring patient safety, we have been mandated to cut resident work hours to 80 hours per week. This has forced us to develop alternative approaches to patient care that do not involve resident participation at various times. The widespread use of what we call ‘‘clinical surgical specialists,’’ nonphysician health care providers, has introduced an entirely new set of issues with which we as surgical educators must deal. The restriction in resident work hours has caused us to focus very specifically on the balance, or lack thereof, between service and education. Whereas in the past the education often took a back seat to the service role of the resident, the reduced hours residents are allowed to work today have given us the opportunity to focus on the education component, where our efforts should have been directed all along. The changing demographics of students entering medical school has also mandated a change in the way we think about surgical education. Now that medical school classes are comprised of at least 50% women, a group that classically has not flocked to surgery as a profession, we are under increasing pressure to make the specialty more attractive, starting with the education component. Students entering medical school today have a different set of values than students who entered 20 years ago. There is more of a global perspective, and an increasing awareness of service, as opposed to the desire to generate a large income. Students in medical school today cite lifestyle issues as the single most important influence in choosing a specialty. The next generation of * Corresponding author. E-mail address: [email protected] (L.R. Kaiser). 0039-6109/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.suc.2004.06.012 surgical.theclinics.com
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surgeons will come into the specialty and remake the lifestyle, just as we are remaking the residency now. Reimbursement for surgical services has continued in a steady decline over the past 15 years, while the cost of doing business, particularly the cost of malpractice insurances, has continued to increase or even skyrocket in some states, such as Pennsylvania. Those of us who have been educated in university residency programs and continue in faculty positions at university programs develop a somewhat skewed view of the world of surgery, and periodically need to remind ourselves that ours is not the only world. Less than one fourth of surgical manpower resides in academic medical centers, and thus the majority of surgical care, whether we readily admit it or not, is delivered outside of such centers. The challenge for the surgical educator, whether in an academic medical center or in a freestanding community-based program, remains how to most effectively educate the surgeons of tomorrow so that American surgical care remains the finest in the world. Major change that will affect the profession of surgery for many years to come has occurred, and continues to occur at multiple levels. In fact, the changes occurring now may be the most sweeping to occur since the advent of the Halstedian residency system. As we have alluded to above, these changes begin with the surgery applicant pool, and extend through the radical change that is underway in the recertification process now referred to as ‘‘maintenance of certification.’’ Change in applicant pool Applications to medical school peaked in the mid-1970s, and then declined for a number of years before again beginning to increase. A career in medicine, unfortunately, may no longer be attracting the best and the brightest students. Most students find themselves in debt upon completion of their medical education, often owing significantly more than $100,000. Faced with a minimum 5-year surgery residency and, for many, at least 1 or 2 years more of fellowship, not to mention time spent in the research laboratory for those interested in academic careers, it is easy to see why many are turned off by surgery as a career. Yet in a recent survey, lifestyle issues assumed much greater importance than length of time spent in training [1]. The medical student’s perception of the surgeon’s lifestyle is not a favorable one, especially among women, who remain underrepresented in surgery, particularly in the senior ranks of academic surgery. Attracting women into surgery is one of the greatest challenges facing our specialty , especially in the academic world, because it is even more difficult to convince a woman to pursue a career in academic surgery, mainly because of the constraints imposed by the promotion system. Until recently, there was little flexibility in an academic career model, especially in institutions that retain an ‘‘up or out’’ promotion process. Despite extensions of the probationary period granted for childbirth, the difficulty a woman has in amassing a significant body of scholarly work while establishing a clinical
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practice and raising a family markedly compromises the likelihood of promotion. The flexibility inherent in a private practice makes it significantly more attractive to the woman surgeon. Creating job descriptions for women in academic surgery in which priorities can be aligned appropriately, while allowing for progress toward promotion, remains one of the great challenges to be met as we move forward in the new millennium. We can no longer afford to ignore women in academic surgery, nor should we expect women to be pigeonholed into certain specialties that are more ‘‘suitable’’ for raising a family. Women should be able to pursue the specialty of their choice, while retaining the assurance that issues regarding lifestyle will assume the same level of importance as that accorded to their professional life. This is particularly important if a career in academic surgery is to be at all attractive to women finishing medical school in the twenty-first century. The challenge for those of us in leadership roles in academic surgery is to build enough flexibility into the academic model to make it feasible for both men and women to combine family life with a successful and satisfying academic career. It is no longer acceptable to many people to have all of the sacrifices come from the family side of their lives, and in the future, there will have to be some flexibility on the professional side. Krizek has questioned whether surgery is an impairing profession, and points out a number of elements inherent in our specialty—and specifically in the way we educate those interested in our specialty—that contribute to the development of impairment in the broadest sense [2]. In order to achieve a more acceptable balance between profession and life outside of the profession, changes must begin at the residency level. Concessions must be made to take lifestyle issues into account. Programs in which research education is built into the residency experience for 1 or 2 years do offer the possibility, for instance, of scheduling a pregnancy during that nonclinical time, but many programs do not have such nonclinical time built in. Creative solutions need to be devised to cover maternity leave time for women during surgical residency. As we fully incorporate more nurse practitioners and physician’s assistants into our clinical programs, to cover the service function formerly performed by house staff before work-hour limitations, providing coverage for a resident on maternity leave should become fairly routine. Changing regulatory pressures The institution of work rules has forever changed the face of the surgical residency, and we are just beginning to see how those changes will look. Many questions remain and, in the authors’ estimation, it will take at least 5 years of living with the new rules to draw any conclusions, good or bad, as to the effect of these changes. By this we mean the effect on the end product, the fully trained surgeon. Even this concept is changing. We are not truly now ‘‘training’ surgeons, nor for that matter have we ever done so. One
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would like to think that we educate surgeons, and the work-hour rules have caused us to rethink this issue as well. Training was probably a more accurate term previously, because many programs followed an apprenticetype model, in which trainees put in long hours, mostly performing service work and gathering in what education came their way. In some institutions, the duties of the house staff included transporting patients, drawing blood, obtaining test results, and other service functions that could easily have been performed by nonphysician personnel. These tasks, as well as taking inhouse call, were all part of the price paid, especially in the junior years, for the benefits that would come during the later years of the residency program, the operative cases. Time in the operating room (OR) increased as one progressed through the years of the residency. In many programs, the time spent in the OR during the first year of residency was minimal, and decreased further with the introduction of table-mounted, self-retaining retractors that obviated the need for a junior person to be present. The service requirements outside of the OR took up most of the junior resident’s time, while contributing little to the overall education, though we were loathe to admit it at the time. It was truly the price to be paid to get to the next level. House staff, particularly junior residents, represented to the hospital a very inexpensive labor force, carrying out tasks that would have cost significantly more if paraprofessionals were performing them. If we assume that the cost of a nurse practitioner is $100,000 per year and recognize that they work half as many hours as a resident (40 hours instead of 80 hours) and cover half as many patients (10–12 versus 20–25), then the value of a single resident is approximately $400,000 per year, not an insignificant amount. The work-hour rules have forced surgical educators to become just that—educators. The balance between service and education clearly has changed, and because of the limitation of work hours, surgical program directors have been forced to look closely at the value of every hour spent by residents in the hospital. The authors believe that this is an unintended, though clearly beneficial, consequence of the work-hour rules, and that the framers of these rules had no idea what they were creating. This is not to say that adapting to the limitation of work hours has been or will be easy. There is no convincing evidence to date that limiting work hours for residents will improve patient safety, but the evidence is beginning to accumulate that these restrictions will significantly improve resident education. To provide a surgical education, we must have a curriculum, something that did not previously exist in any formalized fashion under the apprentice model. The curriculum must be well defined, with learning objectives articulated for each rotation and for each level of resident. Obviously, the objectives for a first-year resident on a gastrointestinal surgical service will be different than those for the chief resident on the service. Resident evaluations should be based on these objectives, as should the evaluation of the faculty by the residents. Objectives must be clearly stated, and ideally should be developed jointly by the residents and the
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faculty. Formalizing a curriculum is the only hope of achieving a balanced and complete surgical education, in which the amount of service time, though not zero, must be minimized. Formerly, most residents got the education piece mostly as a function of being present in the hospital for so many hours. It just rubbed off, as it were. And this worked fine for most, mainly because we never looked critically at the process. The Residency Review Committee (RRC) reviewed programs, and the American Board of Surgery (ABS) required certain numbers and types of cases, but no formal process existed to review the education received by the resident. Successful completion of the certifying and qualifying examination of the ABS by a resident finishing an RRC-approved program meant nothing more than that the individual had fulfilled a minimum set of requirements and had passed a written and oral examination. The ABS, or any certifying board for that matter, failed to address the issue of competence or quality of the education, and still does not. None of the qualifying or certifying examinations are designed to discriminate the well-qualified from the less wellqualified individual. To optimally educate residents in fewer hours, the service role formerly performed by them must be assumed by others, usually nurse practitioners and physician assistants, but some are still convinced that the length of the residency will need to be increased as well to make up for these lost hours. The authors remain convinced that the emphasis placed on an objectivebased curriculum and the increased efficiencies inherent in a well thoughtout educational experience will more than make up for the lost hours, most of which formerly were spent nonproductively. This will require, however, some innovations in surgical education, many of which are already being employed. The use of simulators and inanimate training models before coming to the OR and as an adjunct to developing advanced skills will optimize the educational experience in the OR. For example, once laparoscopic skills have been acquired in the inanimate laboratory, not only will the OR experience be more meaningful for the resident, but also safer for the patient: anesthesia time will be shorter and errors in technique fewer. The use of computer simulation, especially with three-dimensional viewing and tactile feedback, will allow the resident to practice complex procedures multiple times before attempting to perform them in the OR. At the completion of a surgery program, the finishing resident may have had fewer cases in number, but the educational experience garnered from each case should be significantly greater. This should cause us to rethink our emphasis on numbers and concentrate more on the quality of the educational experience. The issue of patient safety has assumed greater importance, in the profession and certainly in the mind of the public, who have been deluged with well-publicized horror stories of surgical misadventures. The role of the surgical resident assumes great importance in reducing errors, and surgical programs must take this into account as the educational model changes. For
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optimal patient safety and error reduction, a climate must be created in which attention is directed not at placing blame but at looking at systems approaches to reducing error, not just within the residency program but within the institution as a whole. This involves creating a climate of mutual respect without fear of punitive actions against those who report errors. We as surgical educators need to instill early-on a collegial, team approach to patient care that involves nurses, nurse practitioners and physician assistants, hospitalists, and the patient and family. Thus the teaching of leadership skills should be a part of the curriculum, because team leading is not necessarily an acquired skill for all. Formal instruction, if only minimal, in team leading would go a long way toward creating a collegial environment in which everyone is working together for the good of the patient. A hostile environment in which the first impulse is to place blame will not succeed in improving patient safety. This type of collegial practice has not been part of the surgical residency and represents a new paradigm. This approach needs to be part of the fabric of the institution, so that residents can begin to see surgical practice as a team effort. The team approach will be particularly important as we go forward, because the surgeon can no longer hold himself apart from the other team members. This concept needs to be introduced very early in the resident’s education. The design of the collaborative practice model between residents and midlevel providers is crucial to guard against actually creating more patient safety issues by increasing the dependence on handoffs and communication. Volpp and Grande cited eight problems faced by residents that, if solved, would considerably improve patient safety in his view from a resident’s perspective [3]. The suggested solutions generally fall into three categories: use of technology, improvements in the work environment, and change in the academic culture. Many of these already are in place, including computerized order entry and work-hour limitations, but others, such as computerized sign-out, are less prevalent. Volpp and Grande also stressed the idea of a team approach, and the creation of a collegial culture that rewards the reporting of adverse events. Effort should be directed toward defining systems problems that, if corrected, will reduce or eliminate errors. Residents should be a major part of all efforts in error reduction, and must be key members of the team. To do this, residents cannot be subjected to an increased workload while on duty in order to make up for fewer hours worked overall. Changing educational goals Coinciding with changes being made in the mechanics of the education of the surgical resident is a fundamental change in thinking regarding the specialty of surgery in general. The ABS is currently struggling with the notion of a definition of general surgery, and within that context is trying to structure surgical education to best meet the needs of that specialty and the
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various subspecialties. It is likely that within the next 10 years we will see a restructuring of the surgical residency that will allow those interested in general surgery to pursue that specialty in depth, while allowing those interested in the subspecialties to branch off earlier. There has been much discussion at the ABS level of a core curriculum in surgery that all surgical specialties would have in common, and that would consist of 2 or perhaps 3 years, and the termination of this core would be the jumping-off point for the subspecialties. An examination in basic surgery would be the culmination of the core curriculum to be completed by all trainees, no matter what the specialty. Likely this will assess basic knowledge in surgical principles and surgical-related basic science common to all surgical disciplines. Those interested in general surgery would continue on in an as-yet-to-be-named program in ‘‘advanced general surgery’’ or some other apt title. This would distinguish these individuals as specialists in their own right, but is greatly dependent on how the specialty becomes defined. Likely there will be several tracks, including one in rural surgery, for which the curriculum would include some additional subspecialty education such as gynecology, urology, and perhaps thoracic surgery. Currently there is no timetable articulated for these changes to occur, and for that matter, there has been no official statement that they will occur. The report of the blue ribbon panel appointed by Haile Debas, MD, during his term as president of the American Surgical Association, was presented at the April 2004 meeting of the association, and publication of the recommendations of this group should appear soon. Much discussion and debate remains before such radical change occurs in surgery, but there is a widespread belief that the time has come. The core curriculum in surgery has been discussed for a number of years, but there is a sense now that the time has come, and the report of the blue ribbon panel should serve as a catalyst to move this forward. The funding of graduate medical education will continue to be a challenge. In academic centers, we have an advantage over community hospitals, because departments may accumulate endowment income, with the interest being used to fund at least partial salary support for certain faculty members. This includes the establishment of endowed professorships as well as restricted or unrestricted accounts. Currently, much of the time given to education is unfunded time, and the time this takes from clinical work must somehow be compensated. At the University of Pennsylvania, the department of surgery is fortunate to have a research endowment that was begun in 1877, when D. Hayes Agnew was installed as the first John Rhea Barton Professor of Surgery, the first endowed chair of surgery in the country. Funds have been added to this endowment over the years, and in addition to a number of individual restricted and unrestricted funds, we now have 10 endowed professorships. The use of endowment funds can significantly add to the teaching program, especially if used to support the protected time of junior faculty to aid in faculty development. Community
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hospitals essentially rely completely on volunteer faculty, who recognize that the time spent teaching is uncompensated and is done without the expectation of anything in return expect personal satisfaction. Any type of faculty development in a community hospital has to rely on the individual faculty member. Part of the mission of an academic department of surgery should be to raise money for the endowment, so that teaching and faculty development can continue to be supported. One can envision the change toward a core curriculum occurring over the next 10 years, with a phase-in beginning perhaps within 5 years. This timetable, however, is merely speculation, because there are so many stakeholders who must buy into such a curriculum before its initiation. Already major changes have occurred. As of July 2003, those entering a cardiothoracic training program no longer are required to be certified by the ABS before sitting for the American Board of Thoracic Surgery qualifying examination. This marks a radical departure; however, those entering a cardiothoracic residency still must complete a full RRC-approved general surgery residency. Similarly, the ABS has approved a fast track for both pediatric surgery and vascular surgery that allows for dual board certification in a shortened time frame for those who combine a program in the same institution. Neither vascular surgery nor pediatric surgery has embraced this proposal. Leadership in vascular surgery has been working toward a separate board for a number of years, an effort that has a significant chance of succeeding, and one that has been caused by the major change in the specialty that has occurred over the last decade because of the rise of endovascular procedures. All of these changes will have major implications on the education within a general surgery residency. The creation of a core curriculum based on a broad-based agreement among the various subspecialties may eliminate some of the current problems that arise with slotting of residents in accord with the various wishes of subspecialty program directors. The major emphasis of any core curriculum has to be education, with the service role taking a subservient position. The creation of a core curriculum may also alleviate some of the concern about the loss of ‘‘index’’ cases, which become diluted when everyone competes for them at the senior resident level. With subspecialty tracking, the index cases in general surgery will be covered by those residents pursuing advanced general surgery, thus also addressing the concerns about the adequacy of the educational experience with limited resident work hours. With the move toward earlier delineation of specialization, a number of other concerns arise. Until recently, the surgeon, as the captain of the ship, controlled the care of the patient from admission to discharge, including time in the intensive care unit, if required. The role of the intensivist or critical care specialist has changed some of this, with the changes potentially beginning at the residency level. Most programs expose residents to the intensive care unit (ICU) environment as part of a critical care rotation in
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which they come under the supervision of critical care attending physicians, some of whom are surgeons and some of whom are not. In many settings, the care of the intensive care patient has shifted from the primary surgeon to the intensivist, with the surgeon playing a much more passive role, and in some cases not permitted to write orders. Models of intensive care practice vary from an open model, in which the attending surgeon remains in charge of the patient’s care, with input and assistance from the critical care team, to a closed model, in which the patient is managed solely by the intensive care specialists. In between is a semiclosed model in which the patient is managed primarily by the critical care team, but the attending surgeon remains able to write orders and control the care of the patient. Outside organizations have weighed in on this issue, with the leapfrog group using management of patients in the intensive care setting by intensivists as one of its primary criteria for quality measurement [4]. What are the implications for the resident with the intensivist model? First and foremost, they learn that the care of critically ill patients is better managed by those who do it on a fulltime basis, with resultant improvement in survival and shorter length of ICU stays [5]. The concept of the busy surgeon managing the care of a critically ill patient while spending the day in the OR is no longer viable with the current level of sophistication that exists for the care of the ICU patient. With management decisions often made on a minute-to-minute basis, it is impossible for these patients to be managed from afar. That being said, it is important to realize there is no turning back from this. The model in which ICU patients are managed by intensivists may result in surgical residents lacking the knowledge to manage these patients, and thus they will develop a reliance on this model moving forward, whether they opt for a community or a university-based practice [6]. Surgeons interested in managing critically ill patients will of necessity need to complete a surgical critical care fellowship, and perhaps more individuals at the resident level should be encouraged to do this; otherwise, the care of the critically ill postoperative patients will fall solely to our nonsurgical intensivist colleagues. Is the reliance on the intensivist model necessarily bad? Not necessarily, though it represents a major departure from the way that surgeons have become accustomed to working; however, the changes taking place at the resident level likely will dictate future practice. Taking this argument to its logical conclusion, one must ask if surgeons might become well rested, poorly educated technicians if the care of ICU patients is relinquished and other providers, such as hospitalists, assume the care of postoperative patients. Our early experience with a collaborative resident–midlevel provider model has raised serious concerns that the routine pre- and postoperative care is being shifted to the midlevel providers, and the resident is being relegated to the role of technical student in the OR. We have not seen the full impact of this trend, because currently the collaborative model is only in play during regular daytime work hours, and the residents assume full care in the other 100 or so hours
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per week. This is a concern that must be addressed at the residency level, by making sure that the care of the surgical patient is not lost from the curriculum. Residents must be exposed on a regular basis to the outpatient aspects of surgery by participating in office hours, both to gain the ability to assess patients with surgical problems and make a decision regarding treatment, and to gain some perspective on the follow-up of postoperative patients. There is no question that the mechanics of the care of the surgical inpatient are changing and will be changed forever, as the current generation of residents completes their education. The education of the surgeon is not the only end point in the process. The most significant end point is the delivery of outstanding, safe care to the surgical patient, no matter how the model evolves. Surgical education must be based on this precept, with the recognition that change is inevitable. Concerns about whether in a new model of surgical education we will be able to instill in the resident a sense of responsibility and ownership for the care of the patient are valid, and need to be addressed. In the past, this sense was inculcated by spending countless hours, including nights, in the hospital, without any real sense as to the value of those hours. There is every reason to expect that a collaborative-care model should result in improved care for the patient, though this change will not come easily for surgeons not educated in this model. Our residency system has promoted residents on the basis of time served, and the complexity of the cases performed by an individual resident is usually tied to the seniority of the resident; that is, a clinical fourth-year resident will have more responsibility both within and outside of the OR than a second-year resident. Rarely is a resident held back in a surgical program, even if significant deficiencies have been noted. We need to move toward a system where advancement in the residency program and completion of the program is tied to demonstrated competence, not just the completion of a specified number of years. This is in accord with the six core competencies put forth by the Accreditation Council for Graduate Medical Education (ACGME) and mandated to be addressed beginning with the residency program. These core competencies also form the basis and guidelines for lifelong learning. Residents, and for that matter, medical students, will need to be assessed on the basis of these core competencies. It is naive to assume that all individuals entering a surgical residency will be competent to practice surgery after 5 clinical years. Some may require more than 5 years, and it is incumbent upon us to recognize these individuals, and to predicate advancement on the development of certain skills, not just on time served. To optimally evaluate resident performance, the objectives for each rotation at each level need to be met before advancement can occur. Not all residents will develop surgical skills at the same rate, and this fact has to be incorporated into our thinking about residency education. With the focus on education, we should be able to better individualize a resident’s experience than we have done previously.
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Change in the public’s expectations What is reasonable for members of the public to expect when they enter a teaching hospital? It is assumed that patients coming to a university hospital recognize that residents and fellows will be involved in their care. There is a clear lack of understanding as to the extent of the involvement of these individuals in their care, but it is safe to assume that most people expect their care to be provided by their attending surgeon. Where then does the resident fit into this scenario? How do we handle the patient who insists that the attending surgeon perform the operation? These are sensitive issues and are not unique to the university setting, but are shared with community teaching hospitals as well. How do we continue to try to answer the public’s demand for perfection while providing an education for our successors? Paradoxically, the limitation of residents’ work hours may be an advantage, because their education must be the paramount concern during the hours residents are in the hospital, allowing much of the mundane aspects of care to be attended to by other providers who provide consistency and specialized expertise. The nurse practitioners assigned to a service are a constant; they do not rotate on a monthly or bimonthly basis, and therefore they develop in-depth knowledge of the needs of the particular type of patients under their purview. This can only work toward the patient’s advantage, and experience has shown that patients defer to these individuals who they can communicate with, both in the preoperative and postdischarge settings. Residents need to be integrated into this wellfunctioning system for the sole purpose of coming away with the significant elements of caring for the surgical patient. Much of the residents’ time will be spent in the operating room, where, not being sleep-deprived from a night spent on call, they can pay more attention to the details of the operative procedures. It is reasonable to expect that residents will come to the operating room better prepared for the cases to be performed, having reviewing the records and imaging studies as well as read the relevant text material and pertinent journal articles. Additionally, they might have a chance to do a simulated version of the operation, especially if they are doing a procedure for the first time. There is every reason to expect that the teaching in the operating room can become a more valuable experience with the additional time allotted for preparation. With improved preparation, it is not unreasonable to expect improved concentration, especially in the well-rested resident, and thus a minimization of errors in technique. We must incorporate surgical trainers and simulators to complement the didactic piece, so that the time in the operating room can be used to maximal advantage. Not all of us are great teachers, and residency programs must look closely at this and assign house staff to those who not only are willing to teach, but are willing to work to improve their teaching skills. It will become incumbent upon all of us to improve our skills, so as to maximize use of the residents’ limited time in the most efficient fashion.
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Unless we want to extend the duration of the surgical residency, we must become more efficient in our methods of teaching. This should be facilitated by residents coming to the operating room better prepared for the case to be performed. We need to work with faculty members to enhance their ability to teach in the operating room. Those who already have developed these skills can and should be called upon to work with their faculty colleagues who are not as effective in intraoperative teaching. For instance, when new faculty members are hired directly out of residency, no effort is made to evaluate their teaching ability in the operating room, nor is anyone routinely assigned to work with them to develop these skills. This is an area that invites significant improvement, but we have to be open to such an idea and, up until now, we have not been. Patients expect, appropriately, that they will receive the best possible care. Resident participation should enhance their care, especially for the patient who is critically ill or has a serious medical problem, but this may not always be the case. Patients should be informed that residents will be participating in their care, including their intraoperative care, but they should be reassured that the surgeon will be present for the key portion of the operative procedure. In comparing surgical outcomes between teaching and nonteaching hospitals in the Veterans Administration (VA) hospitals, Khuri and colleagues found that the majority of complex and highrisk cases were done in teaching hospitals within the system, and noted 30day, risk-adjusted mortality rates comparable with those of the nonteaching hospitals [7]. Risk-adjusted, 30-day morbidity rates were higher in some specialties and operations than in the nonteaching setting, however, reflecting either the weak predictive validity of the risk-adjustment models or suboptimal processes and structures of care unique to teaching hospitals. Conversely, Baskett and colleagues demonstrated that operative morbidity and mortality in coronary artery surgery and aortic valve replacement was similar for residents and staff in a single institution in which the residents performed almost 600 cases [8]. Residents performed the cases under direct staff supervision. Being part of a teaching environment implies that care will be managed by a team, not by just one individual, and ideally more attention will be paid to each patient, but this needs to be looked at more closely. It has been recognized by many that, for certain cases, high-volume surgeons have better outcomes than low-volume surgeons [9]. The catch here is that all surgeons have to start as low-volume surgeons. The learning curve associated with certain specialties and certain procedures is well recognized. Working in high-volume hospitals, especially with surgical residents, likely attenuates these learning curves. Changing environmental pressures As we enter this new era of surgical education, a number of pressures exerted from outside the residency program will influence the way we conduct business. Residents generally enter surgical residency with significant debt
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from medical school, often reaching levels greater than $100,000. They enter into a residency program that lasts a minimum of 5 years, going up to 7 or 8 years, and that may include an additional fellowship. The opportunity to moonlight during the residency, particularly during the research years, allows for some of this debt to be paid down. During the clinical years, the entire focus of the resident needs to be on the clinical education; thus moonlighting during this time should be prohibited. It remains to be seen what effect the limitation of resident work hours will have on the case numbers of residents completing surgical programs. There is very little, if any, enthusiasm for lengthening the residency program to make up for the potential lost case volume. Despite declining reimbursements, many individuals look forward to the completion of their residency and the beginning of a practice to relieve them of their debt obligation. Herein lies a dichotomy between an academic program and a community-based program. Most, if not all, residents attracted to a community-based program will go on to the private practice of surgery, often general surgery. These programs mostly do not include any significant research experience, because it is not sought after by the type of individuals attracted to the program. Conversely, most university programs offer residents the opportunity to pursue 1 or 2 years of research, with the expectation that most will take advantage of that opportunity. The thought here is that many of these individuals will pursue careers in academic surgery, and that some will be able to go on to establish independent laboratories and obtain individual funding. If we are to continue to produce these surgeon-scientists, we must continue the mentoring process during the early years of an academic appointment, following the completion of the residency. We in surgery have not taken full advantage of the National Institutes of Health (NIH) K awards, the mentored clinical scientist program, whereas other specialties use these widely. The challenges faced by the young surgeon-scientist in trying to build a successful research career while at the same time building a clinical practice make the advice and counsel of a research mentor invaluable. Just having protected time to pursue research is a major challenge, both from the standpoint of getting started in the laboratory and in complying with federal requirements mandated by an NIH award. Without protected time, it is virtually impossible for a young surgeon to succeed in research, and the research will likely be given up fairly early because the clinical work is required to feed the family. If the research endeavor is not established early, it is more likely than not that it will not be successful. Surgeons are ideal at developing collaborative research ventures with colleagues from other disciplines, because the surgeon can bring unique questions to a research program and has ready access to tissue obtained from the operating room. Funding research training for surgical residents has always been challenging, but is likely to become more so as the NIH budget stabilizes following the major funding increases of the last 5 years. In most
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departments, there is not a sufficient excess of clinical dollars to fund resident research; support must be sought elsewhere and is not easy to find. Residents may apply for support through a number of professional organizations, including the American College of Surgeons and the Association for Academic Surgery, among numerous others. Application may also be made for individual National Research Service Awards. The successful academic department of surgery will set aside protected time for junior faculty interested in pursuing an investigative career, and will find the resources to allow most, if not all, residents to participate in surgical research during the residency. Introducing research training early in the surgical career is more likely to be associated with a successful research career later [10]. Academic departments will need to search for new sources of funding for surgical education as well. The development of corporate partnerships for funding pieces of the academic enterprise will remain important. For example, the funding of a laparoscopic fellow could potentially be supported by a maker of laparoscopic instruments, through an unrestricted educational grant. Chairs of academic departments need to spend a significant amount of time developing the types of relationships with corporate partners that lead to these funding opportunities. It is in developing these types of relationships that academic programs retain a major advantage over their community counterparts. Corporate partners have the resources to partner with an academic program or institution, and often see it as advantageous and validating. These educational partnerships can take many forms, and at the University of Pennsylvania we have benefited greatly from multiple partnerships with United States Surgical Corporation, Storz, Guidant, ComcastSpectacor, Getinge, Ethicon, and others that for many years have recognized a commitment to support surgical education, and have provided much needed resources. Summary It remains the province of academic departments of surgery to educate the future leaders of surgery. This is the single major factor that differentiates academic programs from community programs. This is not to say that academic programs are more important than community programs, only that their missions differ. Not everyone who completes surgical education in an academic program desires to become a surgical leader, but the very nature of our specialty makes all of us leaders in one way or another. Although we always recognize the collaborative nature of surgical practice, there is only one person in charge in the operating room during a surgical procedure. Thus all surgical programs produce leaders in one way or another. It is from the academic programs that the intellectual leaders of the next generation must emerge. In times of change, it becomes even more important to have leaders who are well prepared to face the new
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challenges that lie ahead. Our job as academic surgeons is to equip these leaders with the tools necessary to be successful.
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