- Email: [email protected]
The Changing Surgical Residency
ORIGINAL REPORTS
The Changing Surgical Residency Lynn Chao, MD, Vincent Scarpinato, MD, and Marc K. Wallack, MD St. Vincent’s Catholic Medical Center-Manhattan, New York, New York Change\, n. [F. change, fr. changer] 1. Any variation or alteration; a passing from one state or form to another; as, a change of countenance; a change of habits or principles. From Webster’s Revised Unabridged Dictionary, © 1996, 1998 MICRA, Inc.1 The above is the dictionary meaning of the word “change”— the passage from one state to another. Change is a ubiquitous part of life. We all experience change in every aspects of our lives, both personal and professional. However, we surgeons are slow to adapt to change. We fight it screaming and kicking. We typify the God-complex, taking our cues from this quote: I the Lord do not change. –Malachi 3:6 2 This attitude had pervaded in our residency training. Dr. Richard Welling in his Presidential address at the 2004 Association for Program Directors in Surgery (APDS) meeting likened the surgical residency of the not so distant past to the feudal system of medieval times. It was all work, work, work. There was a strict hierarchy with no formally incorporated educational system. However, despite the resistance, residencies have been changing. In so many ways, the residency of 30 years ago is not that of today or tomorrow. We have seen a change in the profile of residents and a change in the philosophy of residency training as well as changes in society and technology, factors that affect residency training. The profile of the typical surgical resident has definitely changed. Thirty years ago, the typical graduating class of residents was all male, mostly white and cut from the same cloth. Now, however, the picture of a graduating class is much more diversified, with minorities and women in the mix, making for a much more diversified look. The increase in women should come as no surprise as there are more women into medical school as this chart clearly shows. Over the last 30 years, women have gone from a mere 8% of the graduating class to almost 50%.3 This year, at least anecdotally, there seemed to have been a rise in the number of women applying for surgery. This anecdotal evidence is supported by the fact that there is indeed a Correspondence: Inquiries to Marc K. Wallack, MD, Department of Surgery, Cronin 8, St. Vincent’s Catholic Medical Center- Manhattan, 170 West 12th Street, New York, NY 10011; fax: (212) 423-7913; e-mail: [email protected]
444
marked increase in the number of women in surgery over the last decade and a half. The American Medical Association reported in 2001 that there were 4300 women surgeons. Of these women, 75% were under the age of 45 years old.4 In fact in 2002, 25% of ALL surgical residents were women, a number inconceivable 30 years ago.5 Also, there is a difference in the culture of the new surgical resident. Marilyn Moats Kennedy, who spoke to the APDS several years ago, breaks different age groups down into the following groups:
Group
Birth Year
Pre-Boomer Boomer Cusper Buster Netster
1934-1945 1946-1959 1960-1968 1969-1978 1979-1984⫹
Each group holds a different set of values and attitudes towards work. The Boomers, the age of many established surgeons, constitutes 40% of the workforce, while the Busters and Netsters, the age of residents and upcoming residents, combined make up 30%.6 Their differences are significant in the changing profile of the surgical resident. The Boomers, who were your typical residents 30 years ago, had Ozzie Nelson-like characteristics: loyalty to the group, strong teamwork, respect for the chain of command and work over leisure. Financial rewards, material goods and prestige help define the concept of a good life to this group. On the other hand, the Busters and Netsters, the GenXers and post-GenXers, reflect more the characteristics of Kurt Cobain, the icon of the grunge rock movement. Their approach to life is completely different: The individual is more important than the chain of command, lifestyle motivates more than money and prestige, meeting personal rather then group goals is more important and opinions of others is not as important to them as to their parents. In their minds, a good life equals lifestyle and time to themselves rather than financial remuneration and societal admiration. So what does this all mean? How does the changing profile of residents lead to a change in surgical residencies? First, with more women, there are new issues to deal with because until male pregnancy becomes a reality, maternity is an issue that surgical directors must incorporate into their program policies.
CURRENT SURGERY • © 2005 by the Association of Program Directors in Surgery Published by Elsevier Inc.
0149-7944/05/$30.00 doi:10.1016/j.cursur.2004.12.005
Additionally, women have different approaches to patients, work, communications, etc. which need to be understood and incorporated as a positive, rather than as a negative. Finally, with the new resident profile, it also means that lifestyle, family and general personal well-being are factors that are sought after within a surgical residency. This segue ways into the next change, the change in philosophy of surgical residency training. Thirty years ago, the philosophy in surgical residency training focused on unlimited hours, patient service and passive learning. The resident’s primary concern was to care for the patient. Learning would occur in the process through osmosis. Therefore, more time at work, more service, meant more learned. Now, however, the philosophy has changed to incorporate lifestyle issues. Additionally, formal education is considered important. This means structured educational programs with curriculums and evaluations, not just experiential learning. Both the public and the new Buster/Netster residents have influenced this change in philosophy. The work hours issue is a prime example of the changes in surgical residency due to the change in the profile of residents. The new generation of residents want more work hour limits in order to accommodate other aspects of their lives. Much has been spoken and written about this issue. The famous Libby Zion case brought it to the forefront almost two decades ago and this has culminated into a national ACGME requirement for all residencies.7 The fact that the ACGME has the power to alter requirements for residency programs demonstrates the growth of formalized education in surgery. The roots of surgical education started in the barbershop apprentice and then gradually evolved into the Halstead model of the surgical residency. Yet even with Halstead, the concept of education remained through grounded in the diffusion of knowledge via contact with patients, books and attendings, often time in a soporific state. However, about 50 years ago, this started transforming. Prior to 1950, there were 3 different groups providing 3 different accreditations for residencies: the American Hospital Association, which was accrediting based on institutions, the American College of Surgeons and the American Medical Association (AMA). Much like the different championship belts in boxing, this caused confusion and weakened the standing of solid resident training programs. The AMA, recognizing the chaos, finally, had the leaders of each specialty get together and hash out standards, creating conference committees in each field. The Conference Committee on Graduate Training of Surgery was thus formed in 1950 and was one of the first. It was the precursor to the present-day Resident Review Committee (RRC) and marked the institutionalization of surgical education. Over the next 10-15 years, the majority of specialties were able to organize in this fashion. However, with the rise of Medicare, the federal government began to control reimbursements and started to more closely investigate the residency training. When the feds discovered that each RRC was independent, they began to question the lack of uniform standards across all residency training programs. In response to the possibility of the federal
government taking over control of graduate medical education, the Liaison Committee on Graduate Medical Education (LCGME) was established in 1972. It brought all the RRCs under one “roof” and established common standards. It began accrediting residency programs 1975. The LCGME ran into some trouble due to some antitrust issues and a fragile organization and was therefore reorganized and replaced by ACGME in 1981. With the idea of educational accreditation, forward thinking surgical program directors latched onto the idea of formal education and formed the Association of Program Directors in Surgery (APDS) in 1977. The Association for Surgical Education (ASE) was then established in 1980, emphasizing surgical education is a true discipline.8 With the ACGME, residency educators are held accountable to a standard that is nationwide and, importantly, set by our own profession. Programs are required to have such elements as: Goals and Objectives, Competencies, Faculty Quality, Residency Evaluations, Institutional Requirements, Scope of Educations and Duty Hours. The rise of surgical education as a formalized entity has lead to new ideas like Objective Structured Clinical Examination, evidence based learning and standardized patient. These are terms that 30 years ago were never ever contemplated as part of surgical training. With this and the new duty hours, the learning can no longer be passive through experience and exposure. There has been a rethinking of the surgical resident as a student first, rather than as a worker. Debra DaRosa and colleagues published an outstanding example of this type of thinking last year in Surgery.9 The article was the result of a 2-day think tank of surgical educators. The think tank had the task to re-examine different aspects of surgery residency, decide on their importance and then re-think the whole educational experience of the surgical resident. New models of residency were proposed, such as a case based model in which the learning needs of the residents form the basis of case assignments rather than the needs of the attendings. Other ideas such as surgical homework were also offered. This type of creative thinking is demonstrates the importance that education in an organized fashion has taken in surgical residency today. The final, very broad category of change that has lead to changes in surgical residencies must be mentioned, the changes in technology and society. This is a self-evident category but must be included for completeness. The changes in information technology has revolutionized residency, allowing residents a whole new manner in which to access information both about diseases and about patient information. Gone are the days of library research. Evidence based medicine is quicker and easier than ever. X-rays, labs, patient charts, medical texts and journals are all on the Internet and even downloadable to small handheld computers. However, this easy access to information has also led to the changes in patients as they too have more access to information and are savvier than ever. They are less willing to accept the word of the physician and may be less accepting of the student doctor. Reimbursements and litigations have also changed the way residencies can be run. Gone are the old days
CURRENT SURGERY • Volume 62/Number 4 • July/August 2005
445
of ward versus private patients. Every patient has the right to have a fully trained attending surgeon and residents can no longer practice or operate without direct attending supervision. Finally, new medical technology has obviously changed the complexion of residencies. More information can be obtained, making physical diagnosis a lost art form. Also, more medical treatments have taken away some operations. H2 blockers, Interventional radiology and endoscopy have stolen away such procedures as gastrectomies, coronary artery bypasses and portal caval shunts. On the flip side, new technologies have also lead to new procedures to learn; minimally invasive surgery is the most obvious example. In conclusion, surgical residency has changed dramatically from when current surgical leaders trained. We have welcomed the new generation of residents with their new values, greeting women into our field and accepting the concept of lifestyle. We have formalized our educational system with such ideas as evidence based learning and common program requirements. And, we have adapted to the numerous changes in society and technology. These alterations are perhaps the most radical since those made by Halstead at the turn of the century. And, despite our resistance to change, we surgeons have adapted with the same dedication we exhibit to our craft in order to ensure the continuation of quality surgical residency training.
REFERENCES 1. Webster’s Revised Unabridged Dictionary Plainfield, NJ:
MICRA, Inc.; 1998. http://dictionary.reference.com/ search?q⫽change. Website accessed June 14, 2004. 2. Malachi 3:6 . In The New International Version Holy Version. El
Reno, Oklahoma: Rainbow Studies International; 1996.
446
3. Women medical school applicants. Table 2 from the Amer-
ican Medical Association. Updated January 23, 2003; www.ama-assn.org/ama/pub/article/print/171-196.html. Website accessed April 8, 2004. 4. Percent distribution of female physicians by age and special-
ty-2001. Table 15 from the American Medical Association. Updated January 23, 2003; www.ama-assn.org/ama/pub/ article/print/171-7134.html. Website accessed April 8, 2004. 5. Women residents by specialty-2002. Table 4 from the
American Medical Association. Updated January 23, 2003; www.ama-assn.org/ama/pub/article/print/171-198.html. Website accessed April 8, 2004. 6. Age diversity in the workplace. Mini-Resumes. May 2001.
www.rwcaldwell.com/newsletters/rw_caldwell_newsletter_ 1.pdf. Website accessed June 14, 2004. 7. Wallack M, Chao L. Resident work hours: the evolution of
a revolution. Arch Surg 2001;136:1426-1431. 8. Dates in the history of the council on medical education and
graduate medical education. In Guidebook for GME Program Directors. USA: American Medical Association; 2003: 80-81. http://www.ama-assn.org/ama1/pub/upload/ mm/410/gmehandbook_appg.pdf. Website accessed June 14, 2004. 9. DaRosa DA, Bell RH, Dunnington GL. Residency pro-
gram models, implications, and evaluation: results of a think tank consortium on resident work hours. Surgery 2003;133(1):13-23.
CURRENT SURGERY • Volume 62/Number 4 • July/August 2005
The Changing Surgical Residency Lynn Chao, MD, Vincent Scarpinato, MD, and Marc K. Wallack, MD St. Vincent’s Catholic Medical Center-Manhattan, New York, New York Change\, n. [F. change, fr. changer] 1. Any variation or alteration; a passing from one state or form to another; as, a change of countenance; a change of habits or principles. From Webster’s Revised Unabridged Dictionary, © 1996, 1998 MICRA, Inc.1 The above is the dictionary meaning of the word “change”— the passage from one state to another. Change is a ubiquitous part of life. We all experience change in every aspects of our lives, both personal and professional. However, we surgeons are slow to adapt to change. We fight it screaming and kicking. We typify the God-complex, taking our cues from this quote: I the Lord do not change. –Malachi 3:6 2 This attitude had pervaded in our residency training. Dr. Richard Welling in his Presidential address at the 2004 Association for Program Directors in Surgery (APDS) meeting likened the surgical residency of the not so distant past to the feudal system of medieval times. It was all work, work, work. There was a strict hierarchy with no formally incorporated educational system. However, despite the resistance, residencies have been changing. In so many ways, the residency of 30 years ago is not that of today or tomorrow. We have seen a change in the profile of residents and a change in the philosophy of residency training as well as changes in society and technology, factors that affect residency training. The profile of the typical surgical resident has definitely changed. Thirty years ago, the typical graduating class of residents was all male, mostly white and cut from the same cloth. Now, however, the picture of a graduating class is much more diversified, with minorities and women in the mix, making for a much more diversified look. The increase in women should come as no surprise as there are more women into medical school as this chart clearly shows. Over the last 30 years, women have gone from a mere 8% of the graduating class to almost 50%.3 This year, at least anecdotally, there seemed to have been a rise in the number of women applying for surgery. This anecdotal evidence is supported by the fact that there is indeed a Correspondence: Inquiries to Marc K. Wallack, MD, Department of Surgery, Cronin 8, St. Vincent’s Catholic Medical Center- Manhattan, 170 West 12th Street, New York, NY 10011; fax: (212) 423-7913; e-mail: [email protected]
444
marked increase in the number of women in surgery over the last decade and a half. The American Medical Association reported in 2001 that there were 4300 women surgeons. Of these women, 75% were under the age of 45 years old.4 In fact in 2002, 25% of ALL surgical residents were women, a number inconceivable 30 years ago.5 Also, there is a difference in the culture of the new surgical resident. Marilyn Moats Kennedy, who spoke to the APDS several years ago, breaks different age groups down into the following groups:
Group
Birth Year
Pre-Boomer Boomer Cusper Buster Netster
1934-1945 1946-1959 1960-1968 1969-1978 1979-1984⫹
Each group holds a different set of values and attitudes towards work. The Boomers, the age of many established surgeons, constitutes 40% of the workforce, while the Busters and Netsters, the age of residents and upcoming residents, combined make up 30%.6 Their differences are significant in the changing profile of the surgical resident. The Boomers, who were your typical residents 30 years ago, had Ozzie Nelson-like characteristics: loyalty to the group, strong teamwork, respect for the chain of command and work over leisure. Financial rewards, material goods and prestige help define the concept of a good life to this group. On the other hand, the Busters and Netsters, the GenXers and post-GenXers, reflect more the characteristics of Kurt Cobain, the icon of the grunge rock movement. Their approach to life is completely different: The individual is more important than the chain of command, lifestyle motivates more than money and prestige, meeting personal rather then group goals is more important and opinions of others is not as important to them as to their parents. In their minds, a good life equals lifestyle and time to themselves rather than financial remuneration and societal admiration. So what does this all mean? How does the changing profile of residents lead to a change in surgical residencies? First, with more women, there are new issues to deal with because until male pregnancy becomes a reality, maternity is an issue that surgical directors must incorporate into their program policies.
CURRENT SURGERY • © 2005 by the Association of Program Directors in Surgery Published by Elsevier Inc.
0149-7944/05/$30.00 doi:10.1016/j.cursur.2004.12.005
Additionally, women have different approaches to patients, work, communications, etc. which need to be understood and incorporated as a positive, rather than as a negative. Finally, with the new resident profile, it also means that lifestyle, family and general personal well-being are factors that are sought after within a surgical residency. This segue ways into the next change, the change in philosophy of surgical residency training. Thirty years ago, the philosophy in surgical residency training focused on unlimited hours, patient service and passive learning. The resident’s primary concern was to care for the patient. Learning would occur in the process through osmosis. Therefore, more time at work, more service, meant more learned. Now, however, the philosophy has changed to incorporate lifestyle issues. Additionally, formal education is considered important. This means structured educational programs with curriculums and evaluations, not just experiential learning. Both the public and the new Buster/Netster residents have influenced this change in philosophy. The work hours issue is a prime example of the changes in surgical residency due to the change in the profile of residents. The new generation of residents want more work hour limits in order to accommodate other aspects of their lives. Much has been spoken and written about this issue. The famous Libby Zion case brought it to the forefront almost two decades ago and this has culminated into a national ACGME requirement for all residencies.7 The fact that the ACGME has the power to alter requirements for residency programs demonstrates the growth of formalized education in surgery. The roots of surgical education started in the barbershop apprentice and then gradually evolved into the Halstead model of the surgical residency. Yet even with Halstead, the concept of education remained through grounded in the diffusion of knowledge via contact with patients, books and attendings, often time in a soporific state. However, about 50 years ago, this started transforming. Prior to 1950, there were 3 different groups providing 3 different accreditations for residencies: the American Hospital Association, which was accrediting based on institutions, the American College of Surgeons and the American Medical Association (AMA). Much like the different championship belts in boxing, this caused confusion and weakened the standing of solid resident training programs. The AMA, recognizing the chaos, finally, had the leaders of each specialty get together and hash out standards, creating conference committees in each field. The Conference Committee on Graduate Training of Surgery was thus formed in 1950 and was one of the first. It was the precursor to the present-day Resident Review Committee (RRC) and marked the institutionalization of surgical education. Over the next 10-15 years, the majority of specialties were able to organize in this fashion. However, with the rise of Medicare, the federal government began to control reimbursements and started to more closely investigate the residency training. When the feds discovered that each RRC was independent, they began to question the lack of uniform standards across all residency training programs. In response to the possibility of the federal
government taking over control of graduate medical education, the Liaison Committee on Graduate Medical Education (LCGME) was established in 1972. It brought all the RRCs under one “roof” and established common standards. It began accrediting residency programs 1975. The LCGME ran into some trouble due to some antitrust issues and a fragile organization and was therefore reorganized and replaced by ACGME in 1981. With the idea of educational accreditation, forward thinking surgical program directors latched onto the idea of formal education and formed the Association of Program Directors in Surgery (APDS) in 1977. The Association for Surgical Education (ASE) was then established in 1980, emphasizing surgical education is a true discipline.8 With the ACGME, residency educators are held accountable to a standard that is nationwide and, importantly, set by our own profession. Programs are required to have such elements as: Goals and Objectives, Competencies, Faculty Quality, Residency Evaluations, Institutional Requirements, Scope of Educations and Duty Hours. The rise of surgical education as a formalized entity has lead to new ideas like Objective Structured Clinical Examination, evidence based learning and standardized patient. These are terms that 30 years ago were never ever contemplated as part of surgical training. With this and the new duty hours, the learning can no longer be passive through experience and exposure. There has been a rethinking of the surgical resident as a student first, rather than as a worker. Debra DaRosa and colleagues published an outstanding example of this type of thinking last year in Surgery.9 The article was the result of a 2-day think tank of surgical educators. The think tank had the task to re-examine different aspects of surgery residency, decide on their importance and then re-think the whole educational experience of the surgical resident. New models of residency were proposed, such as a case based model in which the learning needs of the residents form the basis of case assignments rather than the needs of the attendings. Other ideas such as surgical homework were also offered. This type of creative thinking is demonstrates the importance that education in an organized fashion has taken in surgical residency today. The final, very broad category of change that has lead to changes in surgical residencies must be mentioned, the changes in technology and society. This is a self-evident category but must be included for completeness. The changes in information technology has revolutionized residency, allowing residents a whole new manner in which to access information both about diseases and about patient information. Gone are the days of library research. Evidence based medicine is quicker and easier than ever. X-rays, labs, patient charts, medical texts and journals are all on the Internet and even downloadable to small handheld computers. However, this easy access to information has also led to the changes in patients as they too have more access to information and are savvier than ever. They are less willing to accept the word of the physician and may be less accepting of the student doctor. Reimbursements and litigations have also changed the way residencies can be run. Gone are the old days
CURRENT SURGERY • Volume 62/Number 4 • July/August 2005
445
of ward versus private patients. Every patient has the right to have a fully trained attending surgeon and residents can no longer practice or operate without direct attending supervision. Finally, new medical technology has obviously changed the complexion of residencies. More information can be obtained, making physical diagnosis a lost art form. Also, more medical treatments have taken away some operations. H2 blockers, Interventional radiology and endoscopy have stolen away such procedures as gastrectomies, coronary artery bypasses and portal caval shunts. On the flip side, new technologies have also lead to new procedures to learn; minimally invasive surgery is the most obvious example. In conclusion, surgical residency has changed dramatically from when current surgical leaders trained. We have welcomed the new generation of residents with their new values, greeting women into our field and accepting the concept of lifestyle. We have formalized our educational system with such ideas as evidence based learning and common program requirements. And, we have adapted to the numerous changes in society and technology. These alterations are perhaps the most radical since those made by Halstead at the turn of the century. And, despite our resistance to change, we surgeons have adapted with the same dedication we exhibit to our craft in order to ensure the continuation of quality surgical residency training.
REFERENCES 1. Webster’s Revised Unabridged Dictionary Plainfield, NJ:
MICRA, Inc.; 1998. http://dictionary.reference.com/ search?q⫽change. Website accessed June 14, 2004. 2. Malachi 3:6 . In The New International Version Holy Version. El
Reno, Oklahoma: Rainbow Studies International; 1996.
446
3. Women medical school applicants. Table 2 from the Amer-
ican Medical Association. Updated January 23, 2003; www.ama-assn.org/ama/pub/article/print/171-196.html. Website accessed April 8, 2004. 4. Percent distribution of female physicians by age and special-
ty-2001. Table 15 from the American Medical Association. Updated January 23, 2003; www.ama-assn.org/ama/pub/ article/print/171-7134.html. Website accessed April 8, 2004. 5. Women residents by specialty-2002. Table 4 from the
American Medical Association. Updated January 23, 2003; www.ama-assn.org/ama/pub/article/print/171-198.html. Website accessed April 8, 2004. 6. Age diversity in the workplace. Mini-Resumes. May 2001.
www.rwcaldwell.com/newsletters/rw_caldwell_newsletter_ 1.pdf. Website accessed June 14, 2004. 7. Wallack M, Chao L. Resident work hours: the evolution of
a revolution. Arch Surg 2001;136:1426-1431. 8. Dates in the history of the council on medical education and
graduate medical education. In Guidebook for GME Program Directors. USA: American Medical Association; 2003: 80-81. http://www.ama-assn.org/ama1/pub/upload/ mm/410/gmehandbook_appg.pdf. Website accessed June 14, 2004. 9. DaRosa DA, Bell RH, Dunnington GL. Residency pro-
gram models, implications, and evaluation: results of a think tank consortium on resident work hours. Surgery 2003;133(1):13-23.
CURRENT SURGERY • Volume 62/Number 4 • July/August 2005