- Email: [email protected]
The Education of an Academic Surgeon
Journal of Surgical Research 97, 1– 8 (2001) doi:10.1006/jsre.2000.6076, available online at http://www.idealibrary.com on
PRESIDENTIAL ADDRESS The Education of an Academic Surgeon David I. Soybel, M.D. Harvard Medical School, Boston and West Roxbury, Massachusetts 02215 Presented at the Annual Meeting of the Association for Academic Surgery, Tampa, Florida, November 2– 4, 2000
surgeons. To do this, I must talk about what education is generally and why I think the word education may properly be applied to what we, as academic surgeons, do. In addition, I must spend some time talking about who we academic surgeons are and what our goals ought to be in educating the next generations. Only then, after discussing these preliminary ideas, will I feel comfortable in sharing my thoughts about how we ought to structure the environment for the education of students and residents. In framing this discussion, it is my hope that all of us will go back to our respective Departments of Surgery and ask ourselves whether we, our peers, and our bosses have been thinking hard enough about who we academic surgeons are and how we academic surgeons educate others to become . . . us.
I. INTRODUCTION
Today, I want to talk about “The Education of an Academic Surgeon.” I am not a professional educator. I have not taken special courses in theory or in the practice of education. It was not until I became a director of student clerkships that I was even offered such organized instruction. But the desire to teach was, and remains, my fundamental motivation for choosing an academic career. I chose the field of surgery, in large part, because it was where I thought I would be the best teacher I could be. I do not want to be misunderstood. I love solving the problems we general surgeons are asked to confront at the bedside and in the operating room. I get much pleasure from my research and I am continually fascinated with the cellular processes of gastric acid secretion and the pathophysiology of gastric mucosal injury. But if it were not for the students, residents, and research fellows, the practice of surgery and the pursuit of research would be stimulating and rewarding— but not more so than other good jobs. For me, academic surgery is a joy. And my joy comes from sharing moments of learning with students, structuring the environment that leads to maturation of residents, and guiding the processes of discovery and innovation by research fellows. For me personally, it is teaching that makes academic surgery a calling. So much for my personal passion for teaching. Is it important? I take it, almost as an article of faith, that educating the next generation of young academic surgeons is the most important thing that we, as the community of academic surgeons, do. But this is a proposition, not an argument; it is not, by itself, a call for action or change. Today, I want to take a good look at the process by which we educate younger people to become academic
II. WHAT IS EDUCATION?
What is education? The word education comes from the Latin verb, educare, which means “to lead out of.” It is a rich word conjuring images of the natural philosopher Aristotle in the ancient lyceum and the physicist Richard Feynman in a modern classroom. One of the most interesting teachers I ever heard was James Redfield, a professor of Greek language and literature at the University of Chicago. In talking about the aims of undergraduate education, he said [1]: . . . the aims of education are the aims of life; education is simply the general term for the process by which we become wiser than we were . . .
Professor Redfield pointed out that people become educated through many paths—in school, in the military, in training for a marathon, or on the road. And he went on to note that, from such considerations, we might underestimate the value of formal schooling. In Charles Dickens’ Pickwick Papers, the aged Mr.
1
0022-4804/01 $35.00 Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
2
JOURNAL OF SURGICAL RESEARCH: VOL. 97, NO. 1, MAY 1, 2001
Weller describes to Mr. Pickwick the path that he chose for his son, Samuel. He says [2]: I took a good deal o’ pains with his eddication, sir; let him run in the streets when he was very young and shift for hisself. It’s the only way to make a boy sharp, sir.
This, at least, was a philosophy, carrying with it a rationale based on a father’s experience and his understanding of what made the world work. We may laugh at the comedy, but let us ask ourselves whether we do not act, more often than not, in accordance with the theory that our students can shift for themselves. And so, we may well ask, if education is so readily obtained on the job or in the streets, who needs school? Well, one easy and rather obvious answer is that real life can be risky and complicated. So perhaps education— general education—might prepare people to deal with challenges that are otherwise too complicated and to learn from failures that might otherwise be too overwhelming. After all, in some jobs and on many streets, people can get hurt. And so, Professor Redfield argued [1], the function of an undergraduate educational institution . . . is to institutionalize failure, to control failure and set some tolerable limits on it . . . An educational institution tries to match the problems to the student, to set him a challenge just a bit more difficult than the last, to allow him to fail without obliterating him so that he can fail again and finally succeed.
The responsibility of the educator is not necessarily to keep students from failing. Rather, it is to make sure that when they fail, they do not get hurt too badly. Now, “medical school” is a postundergraduate endeavor and most think of it primarily as a preparation for a career. Some still think of it as glorified “trade school.” Many might argue that, for these and other reasons, it is wholly inappropriate for us to use the word education when we are describing the path to becoming a surgeon, academic or otherwise. The word we usually use to describe the process by which someone becomes a surgeon also says a lot: we call it training. The word surgery itself suggests more humble origins among the trades or crafts. According to the Oxford English Dictionary, “surgery” is derived from chirurgerie, which is an amalgamation of two words from ancient Greek: cheir (which means hand) and ergon (which means work). Historically, surgeons were not counted among the learned professions and it would seem that they themselves preferred to keep company with craftsmen of the guilds rather than with doctors in the universities [3]. So if I say that we teach surgery, history and imagery suggest that we academic surgeons are much like master tradesmen, teaching specialized kinds of knowledge, judgments, and skills. Unless we thought about it for a while, we would not immediately describe what we do as engaging students and residents in a process by which they become wiser and better human beings than they were. Neverthe-
less, I submit that this is exactly what we do and that is, in part, why what we do can be called education. The other thing that makes what we do education is our obligation to teach our students how to deal with and learn from mistakes. Now, you will perceive instantly that this is a thorny problem, especially if patients’ lives and well-being are at stake. Right now, however, let me say that I am not arguing even subliminally that it is acceptable for patients to get hurt in order for students or interns to learn. At the same time, I do not see how it possible to teach young people how to shoulder weighty responsibilities, if weighty responsibilities are not given to them. Nor do I think it is likely that students can be taught how to succeed as surgeons, investigators, teachers, or administrators, if they have not been taught to learn from failure. So the problem of educating future academic surgeons comes down, in part, to creating an environment in which our students can learn how to respond to failures that are peculiar to surgery and to academics and to teaching our young how to recognize, acknowledge, and learn from the mistakes that we academic surgeons may actually make. III. WHAT IS AN ACADEMIC SURGEON?
In order to understand the process by which our students and residents become academic surgeons, we must actually define who we academic surgeons are, what we do, and what makes us different. Let us start with the words. The term academic surgeon is a composite, reflecting a component that is professional and a component that professes. Both terms, as well as the related word “professor,” come from the Latin word professus, which is the past participle of the Latin verb profiteri, which means “to avow publicly.” The professional component is the surgeon who practices, publicly displaying and utilizing his or her knowledge and skills. But . . . and this is the key . . . he or she does so for the sake of his or her patients. What exactly does this mean? The surgeon is a doctor of medicine, trained after medical school, certified by teachers and colleagues as having the necessary knowledge base, clinical skills, technical skills, and a certain level of experience. In certifying our trainees as “ready” for certification, we, the faculties of the Departments of Surgery, affirm that they are of high character and that they are mature enough to take on responsibilities for the lives, health, and safety of their patients. In some way, we also stipulate that they are capable of learning and growing along with advances within the profession. The component that professes may be more difficult to define. Taking a hint from the derivation, “to profess” certainly means to make a public display of knowledge, judgment, and skill for an audience. But when we talk about “professing” we do not usually
DAVID I. SOYBEL: PRESIDENTIAL ADDRESS
mean in relation to one’s patients or even to the lay public. What we usually mean is that we profess in relation to those who are educated or being educated to understand what is being professed. In other words, in the community of academic surgeons, the audience for the professor is either one’s students or one’s peers. Now, it seems to me that there are two levels at which we profess, corresponding to some extent to the two levels of understanding I have just talked about. At the first level is what we teach the students and residents in order that they become safe, skilled, and compassionate practitioners: what we might call teaching the state of the art. This is what every attending surgeon ought to be teaching, whenever he or she is taking care of patients in the company of students and residents. Such things are often best taught in the course of caring for specific patients, because the interactions are based on the maturity of the learners and the specific circumstances of the patient. Some people identify this as a case method of teaching. But it could certainly be labeled as a form of “apprenticeship,” since the learners are helping to take care of the patients in return for the opportunities to learn and to be supervised in the development of their knowledge, judgment, and skills. At the second level, I would argue that if professing means anything, it means being an expert at something. What kinds of expertise are there? In our world of academic surgery, I count five fairly distinct types and I would like to take a few moments to discuss each in some detail. First, there is the expertise in clinical and operative surgery itself. One mark of such expertise is breadth of experience and excellence of judgment and skill. But what distinguishes it is a special brand of curiosity. Every Department of Surgery has its heroes who are this kind of expert. When I was a student at the University of Chicago, Dr. George Block was the guy who had been there and done it all in the operating room. But what also lay behind Dr. Block’s mastery of his field was his passion for asking what went wrong and why, what could have been done better, and what could he learn and then teach others about his experience. When the students and residents talked about being a master surgeon, he was the one who towered as the role model—in what was an amazingly talented and innovative faculty. Second, there was the expertise that comes with being an innovator—someone who tries to do things previously considered too risky or not yet dreamed of. During my formative years it was the field of solid organ transplantation that seemed to spawn the newest generation of innovators in the operating room— people like David Hume, Joseph Murray, Michael DeBakey, Norman Shumway, and Tom Starzl. These people did not just perform new operations; in fact,
3
they developed entire systems of care that would support major innovations in surgery, based on targeted laboratory research, critical examination of outcomes, partnerships with individuals in a wide variety of disciplines, and support from social and political institutions. These individuals were not just innovators in new treatments but in the creation of systems of care for patients. Third, there is the expertise that comes with pursuit of laboratory investigation, especially the kind that may lead to better understanding and better care of our patients. No example could be more appropriate than that of Dr. Judah Folkman, who single-mindedly dogged a seemingly irrelevant observation—that implantation of tumor cells could turn a rabbit’s lens into a substrate for angiogenesis—and then turned it into a triumph for our understanding of how solid-tissue cancers behave and a revolution in our thinking about how such cancers might be treated. Lately, of course, everyone seems to be clamoring for a fourth kind of expertise: the kind that can analyze the role of surgical care and innovation in various systems of health care delivery, determine the cost, and negotiate the price. I, of course, have been blessed to have Mike Zinner as my Chairman at the Brigham and Women’s Hospital. I have been equally fortunate in having Shukri Khuri as my Department Chief in the Boston V. A. Healthcare System. Both Dr. Zinner and Dr. Khuri have had major impacts on the way we understand how to deliver surgical care, whether it is done in the private sector or in vertically integrated, government-regulated systems such as the V. A. Each of them has had a profound influence on me personally and I am grateful for their time, patience, and understanding. Finally, there is what I would call the expertise of the educator, that is, the person who thinks clearly about how one enables the students and residents to be the best that they can be. It is of interest to me that this kind of expertise has not received much formal attention, but I have heard a lot about it in informal conversation and anecdotes. This is often couched in the recitation of a particular surgeon’s legacies—the recitation of the people who trained under that person and the fact that those trainees and junior faculty hires are now famous or powerful. When we talk about the legacies of Halsted, Rhoads, or Sabiston, we are really paying homage to standards of excellence that these individuals inculcated into their students and residents. I would include the chairman of my residency in Surgery, Dr. Sam Wells, in this company. So, what is an academic surgeon? Before answering this let me share just one more thought: you see, I do not think of academic surgery simply as a collection of academic surgeons, and I do not believe that an academic surgeon can exist apart from colleagues, resi-
4
JOURNAL OF SURGICAL RESEARCH: VOL. 97, NO. 1, MAY 1, 2001
dents, and students. Academic surgery is a community. We academic surgeons are . . . for lack of a better word . . . its citizens and as such we have rights and responsibilities that the community has given us. All of us have obligations for raising its young and, from time to time, some us will have opportunities to lead and or to do something really new and different. And so, when we speak of an academic surgeon, there is, first, what I would call the basic citizen of the community. This is the individual who directs care not only to make sure that the patient gets well but also to serve the educational interests of the residents and students. And I would note that the basic citizenship requirements in academic surgery are pretty inclusive. Mainly what is required is clinical competence and a willingness to be part of the community’s effort to raise the young. The point here is that someone should not be regarded as a citizen of the “academic” simply because he or she holds a teaching appointment and allows patients to be taken care of in a so-called teaching hospital. I do not think that we should identify as academic the attending surgeon who throws out a few clinical pearls of observation or instruction while the resident is “taken through the case.” Even if that attending surgeon is a superb technician with the best judgment, and the residents love to operate with him or her, the term academic does not necessarily apply. In my view, the environment becomes academic only when the care of the patient has been structured with some regard to the best educational interests of the residents and students. And then, among the citizens there are the leaders. These are the people who organize patients to participate in clinical trials, not just the ones who enroll the patients. They are the ones who pick up pipettes or run gels to address unanswered questions, not just the ones who contribute the human tissue to the tissue bank. They are the ones who prepare programs of instruction, not just the ones who prepare an occasional lecture. They are the ones who organize the resources, challenge the faculty, and negotiate the price of excellence and innovation; they are not just the ones with the most lucrative practices. In my view, an academic surgeon is any one who contributes to the intellectual life of a department or the discipline of surgery in a serious, systematic way. But rank, privilege, and selection for leadership in academic surgery go to experts and the people who do new things. IV. THE AIMS OF AN ACADEMIC SURGEON’S EDUCATION
With these considerations in view, we can now ask what should be the goals of training? What are the aims of the trainee’s education? Asking the question this way begs other questions, perhaps more important than those just posed. How does the student know he or
she wants to be an academic surgeon? What kind of academic surgeon does the student want to be? It gets harder. How do we know the student can do it? Even if we are the faculty, who are we to say that they might or might not be able to? I would like to digress to talk about these questions, because I think they help us to understand how to answer the overall question about aims. The first question is: how does the student or trainee know that he or she wants to be an academic surgeon? Actually, I do not see how the student can know. The student has not done surgery, much less taken responsibility for decisions at bedside or in the O.R. The student usually does not have the knowledge base to appreciate the potential fields of investigation or innovation that may ultimately be of interest. I think that this is why so many residents change their minds during residency, about what kind of academicians they would like to be and whether they want to be academics or surgeons at all. Most of us would have to say that we did not really know we wanted to be academic surgeons until we had done what academic surgeons do. What do students know when they decide to go into academic surgery? In most cases the student has experienced moments in the O.R. that were intensely interesting and lots of fun. In most cases also, the student has experienced the thrill of being included in the company of residents and attending staff, when everyone was trying, as a team, to solve a difficult problem. In addition, the student has also witnessed and offered the respect and gratitude given to the Chief Resident or the attending physician who has led the team and taught something to everyone. The student wants that admiration. Plus, the surgeon is a leader and has power—and that attracts ambitious people. What the students know is that they like being with the group and want to be part of it, and ultimately each wants to be the boss. The student takes it on faith that he or she will like doing what academic surgeons do. The second question is: how do we, the faculty, know that the student can do it? Well, it depends. If we are asking, can we make this student a safe surgeon, then the odds are with us. Most anyone graduating from a U.S. medical school can pass the course. If we are asking, can we help this person to become a good citizen in the academic surgical community, then I think we can also answer yes—if we can make him or her a safe surgeon, then we ought to be able to foster the additional habits and skills needed to instruct the young. But if we are asking can this person be molded into an expert and a leader, then I think the answer is, for most cases, we do not know. Every now and then, we can get a glimpse of the potential for great skill, for innovation or discovery, for leadership qualities. I have
DAVID I. SOYBEL: PRESIDENTIAL ADDRESS
been told that Dr. Block’s talents, and those of Dr. Folkman, were obvious well before they began training. But any one who has watched residents come and go in the same place for 10 years knows that not all residents live up to their great expectations and the ones who blossom are not always those we had predicted. Sometimes, the resident who seemed asleep or the one who marched to the beat of a different drummer develops the inextinguishable fire that leads to extraordinary achievement. The lesson is that sometimes we will choose people who will turn out not to know what they are about. We will also have to accept that we—the faculty—will not always be able to help some of them figure it out. In return for taking that risk, we will find great satisfaction in helping the others actually figure it out and take great pleasure in watching some of them do it on their own. Now we can answer the question I posed initially: for any particular individual who has decided to be an academic surgeon, what are the aims of his or her own education? First, one should expect to become a safe surgeon. Second, one should expect to develop the good habits and skills necessary to become an active member of the community that educates the next generation. Third, one ought to spend time, in some sphere of activity important to the Department of Surgery, finding out what it takes and what it feels like to be an expert. I would add that, at some point, one might hope to acquire skills and some appreciation for problems encountered in management and leadership. This is another topic for another day. V. THE EDUCATION OF AN ACADEMIC SURGEON
A. Becoming a safe surgeon. Let me start by asking: what does it take to become a safe surgeon? I doubt that any organization or group of people have thought harder about this than the American Board of Surgery (ABS). This is, after all, its business. Looking broadly at the requirements for certification in General Surgery, we see that the Board wants to know four things in order to “certify” a candidate: (i) Can he or she demonstrate competent understanding of the science of human health and disease? (ii) Can he or she demonstrate competent understanding of the principles of safe surgical practice? (iii) Is there documentation of a certain breadth and quantity of experience with surgical patients, including a record of experience in the operating room as assistant, operating surgeon, or teaching assistant? In addition, the ABS wants a testimonial from the Residency Training Program Director about the uprightness of the candidate’s character. Several years ago, however, the ABS became rather militant about the need for recertification. As soon as you received the letter from Dr. Ritchie congratulating you on becoming a diplomat of the Board, he let you know it was good for 10 years only. More recently, the
5
Board has sought advice about developing programs to assess the quality of surgical practices individually. One idea is that surgeons would be asked to report regularly on operative case-load, case-mix, patient characteristics, and adverse outcomes. Surgeons—and the Board— could then compare their individual practice profiles and outcomes with those of their peers. Now, such moves must be interpreted partly as a response to pressure for the profession to be accountable to third-party payers and other social or political institutions. However, I think we should also view them as our opportunity to improve not just our individual practices, but surgical practice generally. If the experience in the V.A. with the National Surgical Quality Improvement Project has any validity for the private sector, I believe we can predict that keeping score will improve safety and care, not only for individual patients but for whole healthcare systems. These considerations make it clear that becoming a safe surgeon requires a number of different environments—what some call platforms—in which to learn. There must be platforms for learning the science behind health and disease, not just the conclusions but the methods and the reasoning behind them. There must be other platforms for understanding current surgical practice—not just the critical pathways but the evidence behind them and its validity. There must be other platforms for developing technical skills—not just learning how to use surgical instruments, which ones, and when. There may have to be still other platforms for understanding how to report and analyze outcomes and practices, with a specific goal of improving systems. And all the while, there must be an ongoing commitment to the care of individual patients, not only as “platforms” for learning but as human beings who deserve the best efforts of us and our trainees to help them get well. What does all this mean? Most importantly, it means that education of safe surgeons is not to be considered a simple apprenticeship to a group of knowledgeable and experienced practitioners. Rather, it must be considered as a set of programs, some organized in series and some in parallel, with various points of planned interconnection. It is, in other words, a curriculum. The word curriculum itself is derived from the latin verb currere, to run, and was used to denote the course laid out for chariot races in the coliseums of ancient Rome. In this sense, it carries the connotation of running together and is thus closely related to words such as current, currency, courier, and course. The modern usage, of course, refers to the path that students take from entry to completion of their schooling. When I was in college, only a few universities or liberal arts colleges insisted upon a “core” curriculum, that is, a set of required courses of study through which all students would have to pass together in order to be
6
JOURNAL OF SURGICAL RESEARCH: VOL. 97, NO. 1, MAY 1, 2001
considered educated. At that time, the key word on campus was “relevance,” meaning that it should relate to current social problems. Subsequently the ideology seemed to shift to a notion of “relativism,” meaning no one’s ideas or values were better than anyone else’s. Asking all students to follow a preplanned course of study was viewed, at best, as elitism and, at worst, as intolerance. In the late 1980s and 1990s, relativism finally filtered over to medical schools, which were asked to place socially important agendas in the curriculum, as well as to allow students to pursue prolonged periods of individualized study. I would argue that allowing so many paths for so many students has caused the curriculum to splinter. Now, there is no single path rigidly prescribed for all students, but there are also few demands made of any particular student [4]. I believe that the same sort of fragmentation could be said to have occurred in the pathway for training surgeons. Note that the concerns most consistently voiced by the Residency Review Committee in their site visits do not usually have to do with operative caseload and case-mix. Rather, the most common concern is whether the faculty have a structure that allows residents a real presence and responsibility in the pre-, intra-, and postoperative care of any given patient. And the next most common concern is whether the faculty, as an organized collective whole, actually teach, at the patient’s side or in the conference room. These are, in fact, problems of curriculum. Well, how should a faculty develop and implement a curriculum? I think the question answers itself. A curriculum is developed when the faculty, as a group, comes together regularly to discuss the goals, the structure, the problems, the solutions, and the outcomes. A curriculum is implemented when each faculty member thinks, ahead of time, about how the care of an individual patient will be directed so that the patient will do well and the students and trainees will do as well as they can. A curriculum is sustained when the faculty come to conferences, thereby setting an example of the willingness to rethink old ideas, asking questions that lead the students or the experts to ponder new investigation or innovation. A curriculum does not require the faculty to agree on all points of resident selection or training. But there must be, to some extent, discussion and a general acceptance of what is going to be taught, why it is going to be taught, what is to be expected of the trainees, and what is to be expected of the teachers. If there is no consensus about these things, there will be no curriculum. B. Acquiring the skills and habits of life-long learning and teaching. I believe that just about anyone who finishes a surgical residency can be a teacher. There are, of course, some truly gifted teachers and many of us do not have the gift. But I think any
surgeon can be taught to think about the best educational interests of the students and residents while, at the same time, taking good care of patients. Personally, I think it starts with showing students how to organize their thinking and work in relation to common problems—postoperative fever, oliguria, or the acute abdomen or showing residents how to hold a clamp, tie a knot, or position a self-retaining retractor. Residents and senior medical students are delighted to be able to parrot such exercises for their juniors. With reading and thinking, and after taking others through the exercise, they usually end up understanding the problem far better than if they tried to puzzle it out by sitting down with the chapter. Why? Because the question has already been posed by a role model who has established its importance. In addition, teaching forces us to confront what we do not know, in order to give an explanation to someone who wants to know too. When senior medical students applying for residencies talk to me about the desire to teach, this is usually the kind of teaching that they mean. It is direct, personal, and fun. Moving beyond these individual exercises in improving the trainee’s base of knowledge, we also must think about the development of judgment and professional ethics. We want the resident to learn to ponder and then do “what is right.” To do this, we must talk about what decisions we make and why we make them. Out loud, we must talk about how we behave and why we behave that way . . . . Why do we insist that any imaging study— be it an endoscopy or a CT scan— be personally reviewed by the residents who are taking care of the patient? Why not just accept the report of the endoscopist or the radiologist? Why should we insist on obtaining and attending an autopsy on any patient who dies while under our care? Why not just make sure we hear about the result of the pathologist’s examination? The answers are self-evident, but not necessarily to the junior resident who has been up all night with 25 other sick patients. Now come the more uncomfortable questions: What happens if I the teacher also rely on the radiologist’s dictation and do not look at the scan myself? What happens if I could have made the time but chose not to attend the autopsy of a patient who died after an operation that I performed? The students and residents do not necessarily think this is okay. But if I do not show up, then the message to them is that one can get away with it. Go one step further: what is the message to students and residents if the attending surgeons, particularly the full professors or those in positions of leadership, do not regularly attend department conferences? What is the message to junior faculty if expectations of the residents are never earnestly discussed among the faculty as a whole? What is the message if each of the
DAVID I. SOYBEL: PRESIDENTIAL ADDRESS
faculty members is asked to spend 15 to 20 hours in the process of selecting residents for the training program, but is provided with no regular time to develop a consensus about how the residents will be trained. In order to expect exemplary behavior from the young, all of the citizens must set the example. Now, I am not going to swear that my leading thought every day is the best educational interest of the students and residents, even when they can be reconciled with the best interests of the patients. There are pressures to move things along and obstacles to finding time to do everything I should. It is hard to set the right example and it is hard just to try. But I would like to throw out a proposition and that is that the more that any one of us practices doing what is right, the more we tend to do it even when we are tired or distracted. In the Nicomachean Ethics [5], Aristotle said it this way: ethical or moral virtue (in Greek, ethike) is formed by habit (hexis). Doing the right thing . . . setting the right example . . . makes it easier to keep doing the right thing and to teach what is right. And so, when we talk among ourselves about doing what is best for the sake of the patient, and then do it, we are praising it not only to reinforce it for ourselves but so that the young will see that it is a good example to follow. That is why case conferences, particularly the M&M conference, are so important. Case conferences provide the opportunity for the community to praise good decisions and to explain disapproval of bad decisions. Likewise, participation in department meetings where curriculum is discussed is crucial. Such meetings develop consensus. Equally important, the discussion itself puts each of the participants on display for the others. My point is that talking the talk, if done in earnest and in public, will help you walk the walk. C. Becoming an expert. The types of experience, knowledge base, and skill sets needed to develop expertise as a top clinician, innovator, investigator, manager, or educator are certainly different. Nevertheless, one can make some generalizations about what it takes to make a name as an expert. One certainly must learn the common tools of the expert’s trade: knowing how to read the literature critically; learning what kinds of ideas work and how long it takes to get things done; learning how to summarize, analyze, and critique one’s own work; developing a style for writing and presenting short abstracts of promising work; and understanding the processes or peer review and institutional review of new projects or programs. However, the pathways to each form of expertise require a specific knowledge base, a unique skill set, and an opportunity to do something new and untried in a supportive environment. Depending on the kind of work involved, one may have to take advantage of many such opportunities, in order to be sure that the use of the tools has been mastered.
7
The process of becoming an expert takes time and this should not be surprising. After all, if it takes 5 years to become a responsible surgeon, it is not unreasonable to expect that it will take 5 years to become an independent investigator, a mature manager, or a skilled educator. And if such a long period is necessary, the budding expert must realize that the specialized training may only have begun during the 2 or 3 years traditionally set aside in residency for these activities. The remainder of time for development often must be negotiated as part of the first job, requiring time, space, money, a supportive environment, and a proper academic position. In addition to all this, however, most all of us would agree that the path requires a mentor. Recently, much has been said in our academic surgery circles about mentoring. But I would like to put my personal spin on the activity and the rewards of mentoring, as well as to talk about how it fits into to the overall education of an academic surgeon. Who was Mentor? In Homer’s Odyssey [6], Mentor is a trusted friend of Odysseus, left behind in Ithaka to look after the hero’s household and family while Odysseus has gone off to fight the Trojans. After 20 years, however, Odysseus has not yet returned. His household and property have been defiled by suitors to his wife, and Mentor has been powerless to protect them. Interestingly, the actions that define the word “mentor” are not his at all. In fact, it is Athene, the goddess of wisdom and war, who, taking on the likeness and the voice of Mentor, becomes a guide and friend to Odysseus’ son, Telemachus. Telemachus is just coming of age. He has a noble heritage and the right aspirations—to seek out news of his father and to restore order and dignity to the household. But he does not know where to look for his father and he does not know how to take his place in the world. What does Athene, in the likeness of Mentor, do for Telemachus? First, she sees him for who he is, but she can also see ahead to what he can and should become. She asks him uncomfortable questions, all boiling down to one: does he have the right stuff? Her first action is to show him his own internal confusion. Only then does Athene-as-Mentor help him understand what he must do and that he must leave home. She herself then organizes his provisions, companions, and the ship that will see him safely away. Throughout the trip, she plays the role of counselor, advising Telemachus which of the great heroes of the Trojan war he should visit and how to speak with them so as to reflect honor on himself and his father. She points out what his peers (i.e., Orestes) are doing in order to make a name for themselves. Athene-asMentor steps in only to provide advice and encouragement. In this story, she uses her divine powers to intervene only if his life is in danger.
8
JOURNAL OF SURGICAL RESEARCH: VOL. 97, NO. 1, MAY 1, 2001
Over the years, I have thought about the meaning of this relationship between Athene-as-Mentor and the son of Odysseus. At first glance, it seems so straightforward: she shows him the opportunities and organizes the resources and the environment. She encourages, cajoles, introduces him to the right people, and shows him how to network. She lets him work his journey through, basically on his own, unless something really bad is about to happen. At the end, his father is home; Telemachus has the virtues of the Homeric hero and is ready to take his place alongside his father. All this is what I think mentors should do for their prote´ge´s. But it has intrigued me: why couldn’t Mentor himself be the mentor? Why did it have to be Athene? Well, I am not sure. But as I reflect on my own experience as a mentor to some really terrific research fellows, residents, and students, it occurs to me that they helped me to become better than I had been. There is something wonderful, almost magical, in watching them do things I cannot and yet knowing that they need me to be there to watch out for them, to guide them, and to be proud of their accomplishments. And, in reflecting on this privilege, I am tempted to conclude
that it was not that Athene turned into Mentor; rather it was Telemachus who made it possible for Mentor to have a share of the divine. And in the sense that being a mentor helps us to become wiser and better than we could possibly have been before, helping a young, worthy individual to become one of us is the best education for each of us. REFERENCES 1.
2. 3.
4. 5. 6.
Redfield, J. The Aims of Education (address September 24, 1974). In The Aims of Education: The College of the University of Chicago. Chicago: Univ. of Chicago Publications Office, 1997. Pp. 169. Dickens, C. The Posthumous Papers of the Pickwick Club. Harmondsworth, Middlesex, UK: Penguin, 1977. Chap. 20. Rutkow, I. M. The origins of modern surgery. In J. A. Norton, R. R. Bollinger, A. E. Chang, S. F. Lowry, S. J. Mulvihill, H. I. Pass, and R. W. Thompson, (eds.). Surgery: Basic Science and Clinical Evidence. New York: Springer, 2000. Pp. 3. Bloom, A. The Closing of the American Mind. New York: Simon & Schuster, 1987. Aristotole. Nicomachean Ethics. [Translated by M. Ostwald]. Indianapolis: Bobbs-Merrill, 1962. Book II, line 18. Homer’s Odyssey. [Translated by R. Lattimore]. New York: Harper and Row, 1967.
PRESIDENTIAL ADDRESS The Education of an Academic Surgeon David I. Soybel, M.D. Harvard Medical School, Boston and West Roxbury, Massachusetts 02215 Presented at the Annual Meeting of the Association for Academic Surgery, Tampa, Florida, November 2– 4, 2000
surgeons. To do this, I must talk about what education is generally and why I think the word education may properly be applied to what we, as academic surgeons, do. In addition, I must spend some time talking about who we academic surgeons are and what our goals ought to be in educating the next generations. Only then, after discussing these preliminary ideas, will I feel comfortable in sharing my thoughts about how we ought to structure the environment for the education of students and residents. In framing this discussion, it is my hope that all of us will go back to our respective Departments of Surgery and ask ourselves whether we, our peers, and our bosses have been thinking hard enough about who we academic surgeons are and how we academic surgeons educate others to become . . . us.
I. INTRODUCTION
Today, I want to talk about “The Education of an Academic Surgeon.” I am not a professional educator. I have not taken special courses in theory or in the practice of education. It was not until I became a director of student clerkships that I was even offered such organized instruction. But the desire to teach was, and remains, my fundamental motivation for choosing an academic career. I chose the field of surgery, in large part, because it was where I thought I would be the best teacher I could be. I do not want to be misunderstood. I love solving the problems we general surgeons are asked to confront at the bedside and in the operating room. I get much pleasure from my research and I am continually fascinated with the cellular processes of gastric acid secretion and the pathophysiology of gastric mucosal injury. But if it were not for the students, residents, and research fellows, the practice of surgery and the pursuit of research would be stimulating and rewarding— but not more so than other good jobs. For me, academic surgery is a joy. And my joy comes from sharing moments of learning with students, structuring the environment that leads to maturation of residents, and guiding the processes of discovery and innovation by research fellows. For me personally, it is teaching that makes academic surgery a calling. So much for my personal passion for teaching. Is it important? I take it, almost as an article of faith, that educating the next generation of young academic surgeons is the most important thing that we, as the community of academic surgeons, do. But this is a proposition, not an argument; it is not, by itself, a call for action or change. Today, I want to take a good look at the process by which we educate younger people to become academic
II. WHAT IS EDUCATION?
What is education? The word education comes from the Latin verb, educare, which means “to lead out of.” It is a rich word conjuring images of the natural philosopher Aristotle in the ancient lyceum and the physicist Richard Feynman in a modern classroom. One of the most interesting teachers I ever heard was James Redfield, a professor of Greek language and literature at the University of Chicago. In talking about the aims of undergraduate education, he said [1]: . . . the aims of education are the aims of life; education is simply the general term for the process by which we become wiser than we were . . .
Professor Redfield pointed out that people become educated through many paths—in school, in the military, in training for a marathon, or on the road. And he went on to note that, from such considerations, we might underestimate the value of formal schooling. In Charles Dickens’ Pickwick Papers, the aged Mr.
1
0022-4804/01 $35.00 Copyright © 2001 by Academic Press All rights of reproduction in any form reserved.
2
JOURNAL OF SURGICAL RESEARCH: VOL. 97, NO. 1, MAY 1, 2001
Weller describes to Mr. Pickwick the path that he chose for his son, Samuel. He says [2]: I took a good deal o’ pains with his eddication, sir; let him run in the streets when he was very young and shift for hisself. It’s the only way to make a boy sharp, sir.
This, at least, was a philosophy, carrying with it a rationale based on a father’s experience and his understanding of what made the world work. We may laugh at the comedy, but let us ask ourselves whether we do not act, more often than not, in accordance with the theory that our students can shift for themselves. And so, we may well ask, if education is so readily obtained on the job or in the streets, who needs school? Well, one easy and rather obvious answer is that real life can be risky and complicated. So perhaps education— general education—might prepare people to deal with challenges that are otherwise too complicated and to learn from failures that might otherwise be too overwhelming. After all, in some jobs and on many streets, people can get hurt. And so, Professor Redfield argued [1], the function of an undergraduate educational institution . . . is to institutionalize failure, to control failure and set some tolerable limits on it . . . An educational institution tries to match the problems to the student, to set him a challenge just a bit more difficult than the last, to allow him to fail without obliterating him so that he can fail again and finally succeed.
The responsibility of the educator is not necessarily to keep students from failing. Rather, it is to make sure that when they fail, they do not get hurt too badly. Now, “medical school” is a postundergraduate endeavor and most think of it primarily as a preparation for a career. Some still think of it as glorified “trade school.” Many might argue that, for these and other reasons, it is wholly inappropriate for us to use the word education when we are describing the path to becoming a surgeon, academic or otherwise. The word we usually use to describe the process by which someone becomes a surgeon also says a lot: we call it training. The word surgery itself suggests more humble origins among the trades or crafts. According to the Oxford English Dictionary, “surgery” is derived from chirurgerie, which is an amalgamation of two words from ancient Greek: cheir (which means hand) and ergon (which means work). Historically, surgeons were not counted among the learned professions and it would seem that they themselves preferred to keep company with craftsmen of the guilds rather than with doctors in the universities [3]. So if I say that we teach surgery, history and imagery suggest that we academic surgeons are much like master tradesmen, teaching specialized kinds of knowledge, judgments, and skills. Unless we thought about it for a while, we would not immediately describe what we do as engaging students and residents in a process by which they become wiser and better human beings than they were. Neverthe-
less, I submit that this is exactly what we do and that is, in part, why what we do can be called education. The other thing that makes what we do education is our obligation to teach our students how to deal with and learn from mistakes. Now, you will perceive instantly that this is a thorny problem, especially if patients’ lives and well-being are at stake. Right now, however, let me say that I am not arguing even subliminally that it is acceptable for patients to get hurt in order for students or interns to learn. At the same time, I do not see how it possible to teach young people how to shoulder weighty responsibilities, if weighty responsibilities are not given to them. Nor do I think it is likely that students can be taught how to succeed as surgeons, investigators, teachers, or administrators, if they have not been taught to learn from failure. So the problem of educating future academic surgeons comes down, in part, to creating an environment in which our students can learn how to respond to failures that are peculiar to surgery and to academics and to teaching our young how to recognize, acknowledge, and learn from the mistakes that we academic surgeons may actually make. III. WHAT IS AN ACADEMIC SURGEON?
In order to understand the process by which our students and residents become academic surgeons, we must actually define who we academic surgeons are, what we do, and what makes us different. Let us start with the words. The term academic surgeon is a composite, reflecting a component that is professional and a component that professes. Both terms, as well as the related word “professor,” come from the Latin word professus, which is the past participle of the Latin verb profiteri, which means “to avow publicly.” The professional component is the surgeon who practices, publicly displaying and utilizing his or her knowledge and skills. But . . . and this is the key . . . he or she does so for the sake of his or her patients. What exactly does this mean? The surgeon is a doctor of medicine, trained after medical school, certified by teachers and colleagues as having the necessary knowledge base, clinical skills, technical skills, and a certain level of experience. In certifying our trainees as “ready” for certification, we, the faculties of the Departments of Surgery, affirm that they are of high character and that they are mature enough to take on responsibilities for the lives, health, and safety of their patients. In some way, we also stipulate that they are capable of learning and growing along with advances within the profession. The component that professes may be more difficult to define. Taking a hint from the derivation, “to profess” certainly means to make a public display of knowledge, judgment, and skill for an audience. But when we talk about “professing” we do not usually
DAVID I. SOYBEL: PRESIDENTIAL ADDRESS
mean in relation to one’s patients or even to the lay public. What we usually mean is that we profess in relation to those who are educated or being educated to understand what is being professed. In other words, in the community of academic surgeons, the audience for the professor is either one’s students or one’s peers. Now, it seems to me that there are two levels at which we profess, corresponding to some extent to the two levels of understanding I have just talked about. At the first level is what we teach the students and residents in order that they become safe, skilled, and compassionate practitioners: what we might call teaching the state of the art. This is what every attending surgeon ought to be teaching, whenever he or she is taking care of patients in the company of students and residents. Such things are often best taught in the course of caring for specific patients, because the interactions are based on the maturity of the learners and the specific circumstances of the patient. Some people identify this as a case method of teaching. But it could certainly be labeled as a form of “apprenticeship,” since the learners are helping to take care of the patients in return for the opportunities to learn and to be supervised in the development of their knowledge, judgment, and skills. At the second level, I would argue that if professing means anything, it means being an expert at something. What kinds of expertise are there? In our world of academic surgery, I count five fairly distinct types and I would like to take a few moments to discuss each in some detail. First, there is the expertise in clinical and operative surgery itself. One mark of such expertise is breadth of experience and excellence of judgment and skill. But what distinguishes it is a special brand of curiosity. Every Department of Surgery has its heroes who are this kind of expert. When I was a student at the University of Chicago, Dr. George Block was the guy who had been there and done it all in the operating room. But what also lay behind Dr. Block’s mastery of his field was his passion for asking what went wrong and why, what could have been done better, and what could he learn and then teach others about his experience. When the students and residents talked about being a master surgeon, he was the one who towered as the role model—in what was an amazingly talented and innovative faculty. Second, there was the expertise that comes with being an innovator—someone who tries to do things previously considered too risky or not yet dreamed of. During my formative years it was the field of solid organ transplantation that seemed to spawn the newest generation of innovators in the operating room— people like David Hume, Joseph Murray, Michael DeBakey, Norman Shumway, and Tom Starzl. These people did not just perform new operations; in fact,
3
they developed entire systems of care that would support major innovations in surgery, based on targeted laboratory research, critical examination of outcomes, partnerships with individuals in a wide variety of disciplines, and support from social and political institutions. These individuals were not just innovators in new treatments but in the creation of systems of care for patients. Third, there is the expertise that comes with pursuit of laboratory investigation, especially the kind that may lead to better understanding and better care of our patients. No example could be more appropriate than that of Dr. Judah Folkman, who single-mindedly dogged a seemingly irrelevant observation—that implantation of tumor cells could turn a rabbit’s lens into a substrate for angiogenesis—and then turned it into a triumph for our understanding of how solid-tissue cancers behave and a revolution in our thinking about how such cancers might be treated. Lately, of course, everyone seems to be clamoring for a fourth kind of expertise: the kind that can analyze the role of surgical care and innovation in various systems of health care delivery, determine the cost, and negotiate the price. I, of course, have been blessed to have Mike Zinner as my Chairman at the Brigham and Women’s Hospital. I have been equally fortunate in having Shukri Khuri as my Department Chief in the Boston V. A. Healthcare System. Both Dr. Zinner and Dr. Khuri have had major impacts on the way we understand how to deliver surgical care, whether it is done in the private sector or in vertically integrated, government-regulated systems such as the V. A. Each of them has had a profound influence on me personally and I am grateful for their time, patience, and understanding. Finally, there is what I would call the expertise of the educator, that is, the person who thinks clearly about how one enables the students and residents to be the best that they can be. It is of interest to me that this kind of expertise has not received much formal attention, but I have heard a lot about it in informal conversation and anecdotes. This is often couched in the recitation of a particular surgeon’s legacies—the recitation of the people who trained under that person and the fact that those trainees and junior faculty hires are now famous or powerful. When we talk about the legacies of Halsted, Rhoads, or Sabiston, we are really paying homage to standards of excellence that these individuals inculcated into their students and residents. I would include the chairman of my residency in Surgery, Dr. Sam Wells, in this company. So, what is an academic surgeon? Before answering this let me share just one more thought: you see, I do not think of academic surgery simply as a collection of academic surgeons, and I do not believe that an academic surgeon can exist apart from colleagues, resi-
4
JOURNAL OF SURGICAL RESEARCH: VOL. 97, NO. 1, MAY 1, 2001
dents, and students. Academic surgery is a community. We academic surgeons are . . . for lack of a better word . . . its citizens and as such we have rights and responsibilities that the community has given us. All of us have obligations for raising its young and, from time to time, some us will have opportunities to lead and or to do something really new and different. And so, when we speak of an academic surgeon, there is, first, what I would call the basic citizen of the community. This is the individual who directs care not only to make sure that the patient gets well but also to serve the educational interests of the residents and students. And I would note that the basic citizenship requirements in academic surgery are pretty inclusive. Mainly what is required is clinical competence and a willingness to be part of the community’s effort to raise the young. The point here is that someone should not be regarded as a citizen of the “academic” simply because he or she holds a teaching appointment and allows patients to be taken care of in a so-called teaching hospital. I do not think that we should identify as academic the attending surgeon who throws out a few clinical pearls of observation or instruction while the resident is “taken through the case.” Even if that attending surgeon is a superb technician with the best judgment, and the residents love to operate with him or her, the term academic does not necessarily apply. In my view, the environment becomes academic only when the care of the patient has been structured with some regard to the best educational interests of the residents and students. And then, among the citizens there are the leaders. These are the people who organize patients to participate in clinical trials, not just the ones who enroll the patients. They are the ones who pick up pipettes or run gels to address unanswered questions, not just the ones who contribute the human tissue to the tissue bank. They are the ones who prepare programs of instruction, not just the ones who prepare an occasional lecture. They are the ones who organize the resources, challenge the faculty, and negotiate the price of excellence and innovation; they are not just the ones with the most lucrative practices. In my view, an academic surgeon is any one who contributes to the intellectual life of a department or the discipline of surgery in a serious, systematic way. But rank, privilege, and selection for leadership in academic surgery go to experts and the people who do new things. IV. THE AIMS OF AN ACADEMIC SURGEON’S EDUCATION
With these considerations in view, we can now ask what should be the goals of training? What are the aims of the trainee’s education? Asking the question this way begs other questions, perhaps more important than those just posed. How does the student know he or
she wants to be an academic surgeon? What kind of academic surgeon does the student want to be? It gets harder. How do we know the student can do it? Even if we are the faculty, who are we to say that they might or might not be able to? I would like to digress to talk about these questions, because I think they help us to understand how to answer the overall question about aims. The first question is: how does the student or trainee know that he or she wants to be an academic surgeon? Actually, I do not see how the student can know. The student has not done surgery, much less taken responsibility for decisions at bedside or in the O.R. The student usually does not have the knowledge base to appreciate the potential fields of investigation or innovation that may ultimately be of interest. I think that this is why so many residents change their minds during residency, about what kind of academicians they would like to be and whether they want to be academics or surgeons at all. Most of us would have to say that we did not really know we wanted to be academic surgeons until we had done what academic surgeons do. What do students know when they decide to go into academic surgery? In most cases the student has experienced moments in the O.R. that were intensely interesting and lots of fun. In most cases also, the student has experienced the thrill of being included in the company of residents and attending staff, when everyone was trying, as a team, to solve a difficult problem. In addition, the student has also witnessed and offered the respect and gratitude given to the Chief Resident or the attending physician who has led the team and taught something to everyone. The student wants that admiration. Plus, the surgeon is a leader and has power—and that attracts ambitious people. What the students know is that they like being with the group and want to be part of it, and ultimately each wants to be the boss. The student takes it on faith that he or she will like doing what academic surgeons do. The second question is: how do we, the faculty, know that the student can do it? Well, it depends. If we are asking, can we make this student a safe surgeon, then the odds are with us. Most anyone graduating from a U.S. medical school can pass the course. If we are asking, can we help this person to become a good citizen in the academic surgical community, then I think we can also answer yes—if we can make him or her a safe surgeon, then we ought to be able to foster the additional habits and skills needed to instruct the young. But if we are asking can this person be molded into an expert and a leader, then I think the answer is, for most cases, we do not know. Every now and then, we can get a glimpse of the potential for great skill, for innovation or discovery, for leadership qualities. I have
DAVID I. SOYBEL: PRESIDENTIAL ADDRESS
been told that Dr. Block’s talents, and those of Dr. Folkman, were obvious well before they began training. But any one who has watched residents come and go in the same place for 10 years knows that not all residents live up to their great expectations and the ones who blossom are not always those we had predicted. Sometimes, the resident who seemed asleep or the one who marched to the beat of a different drummer develops the inextinguishable fire that leads to extraordinary achievement. The lesson is that sometimes we will choose people who will turn out not to know what they are about. We will also have to accept that we—the faculty—will not always be able to help some of them figure it out. In return for taking that risk, we will find great satisfaction in helping the others actually figure it out and take great pleasure in watching some of them do it on their own. Now we can answer the question I posed initially: for any particular individual who has decided to be an academic surgeon, what are the aims of his or her own education? First, one should expect to become a safe surgeon. Second, one should expect to develop the good habits and skills necessary to become an active member of the community that educates the next generation. Third, one ought to spend time, in some sphere of activity important to the Department of Surgery, finding out what it takes and what it feels like to be an expert. I would add that, at some point, one might hope to acquire skills and some appreciation for problems encountered in management and leadership. This is another topic for another day. V. THE EDUCATION OF AN ACADEMIC SURGEON
A. Becoming a safe surgeon. Let me start by asking: what does it take to become a safe surgeon? I doubt that any organization or group of people have thought harder about this than the American Board of Surgery (ABS). This is, after all, its business. Looking broadly at the requirements for certification in General Surgery, we see that the Board wants to know four things in order to “certify” a candidate: (i) Can he or she demonstrate competent understanding of the science of human health and disease? (ii) Can he or she demonstrate competent understanding of the principles of safe surgical practice? (iii) Is there documentation of a certain breadth and quantity of experience with surgical patients, including a record of experience in the operating room as assistant, operating surgeon, or teaching assistant? In addition, the ABS wants a testimonial from the Residency Training Program Director about the uprightness of the candidate’s character. Several years ago, however, the ABS became rather militant about the need for recertification. As soon as you received the letter from Dr. Ritchie congratulating you on becoming a diplomat of the Board, he let you know it was good for 10 years only. More recently, the
5
Board has sought advice about developing programs to assess the quality of surgical practices individually. One idea is that surgeons would be asked to report regularly on operative case-load, case-mix, patient characteristics, and adverse outcomes. Surgeons—and the Board— could then compare their individual practice profiles and outcomes with those of their peers. Now, such moves must be interpreted partly as a response to pressure for the profession to be accountable to third-party payers and other social or political institutions. However, I think we should also view them as our opportunity to improve not just our individual practices, but surgical practice generally. If the experience in the V.A. with the National Surgical Quality Improvement Project has any validity for the private sector, I believe we can predict that keeping score will improve safety and care, not only for individual patients but for whole healthcare systems. These considerations make it clear that becoming a safe surgeon requires a number of different environments—what some call platforms—in which to learn. There must be platforms for learning the science behind health and disease, not just the conclusions but the methods and the reasoning behind them. There must be other platforms for understanding current surgical practice—not just the critical pathways but the evidence behind them and its validity. There must be other platforms for developing technical skills—not just learning how to use surgical instruments, which ones, and when. There may have to be still other platforms for understanding how to report and analyze outcomes and practices, with a specific goal of improving systems. And all the while, there must be an ongoing commitment to the care of individual patients, not only as “platforms” for learning but as human beings who deserve the best efforts of us and our trainees to help them get well. What does all this mean? Most importantly, it means that education of safe surgeons is not to be considered a simple apprenticeship to a group of knowledgeable and experienced practitioners. Rather, it must be considered as a set of programs, some organized in series and some in parallel, with various points of planned interconnection. It is, in other words, a curriculum. The word curriculum itself is derived from the latin verb currere, to run, and was used to denote the course laid out for chariot races in the coliseums of ancient Rome. In this sense, it carries the connotation of running together and is thus closely related to words such as current, currency, courier, and course. The modern usage, of course, refers to the path that students take from entry to completion of their schooling. When I was in college, only a few universities or liberal arts colleges insisted upon a “core” curriculum, that is, a set of required courses of study through which all students would have to pass together in order to be
6
JOURNAL OF SURGICAL RESEARCH: VOL. 97, NO. 1, MAY 1, 2001
considered educated. At that time, the key word on campus was “relevance,” meaning that it should relate to current social problems. Subsequently the ideology seemed to shift to a notion of “relativism,” meaning no one’s ideas or values were better than anyone else’s. Asking all students to follow a preplanned course of study was viewed, at best, as elitism and, at worst, as intolerance. In the late 1980s and 1990s, relativism finally filtered over to medical schools, which were asked to place socially important agendas in the curriculum, as well as to allow students to pursue prolonged periods of individualized study. I would argue that allowing so many paths for so many students has caused the curriculum to splinter. Now, there is no single path rigidly prescribed for all students, but there are also few demands made of any particular student [4]. I believe that the same sort of fragmentation could be said to have occurred in the pathway for training surgeons. Note that the concerns most consistently voiced by the Residency Review Committee in their site visits do not usually have to do with operative caseload and case-mix. Rather, the most common concern is whether the faculty have a structure that allows residents a real presence and responsibility in the pre-, intra-, and postoperative care of any given patient. And the next most common concern is whether the faculty, as an organized collective whole, actually teach, at the patient’s side or in the conference room. These are, in fact, problems of curriculum. Well, how should a faculty develop and implement a curriculum? I think the question answers itself. A curriculum is developed when the faculty, as a group, comes together regularly to discuss the goals, the structure, the problems, the solutions, and the outcomes. A curriculum is implemented when each faculty member thinks, ahead of time, about how the care of an individual patient will be directed so that the patient will do well and the students and trainees will do as well as they can. A curriculum is sustained when the faculty come to conferences, thereby setting an example of the willingness to rethink old ideas, asking questions that lead the students or the experts to ponder new investigation or innovation. A curriculum does not require the faculty to agree on all points of resident selection or training. But there must be, to some extent, discussion and a general acceptance of what is going to be taught, why it is going to be taught, what is to be expected of the trainees, and what is to be expected of the teachers. If there is no consensus about these things, there will be no curriculum. B. Acquiring the skills and habits of life-long learning and teaching. I believe that just about anyone who finishes a surgical residency can be a teacher. There are, of course, some truly gifted teachers and many of us do not have the gift. But I think any
surgeon can be taught to think about the best educational interests of the students and residents while, at the same time, taking good care of patients. Personally, I think it starts with showing students how to organize their thinking and work in relation to common problems—postoperative fever, oliguria, or the acute abdomen or showing residents how to hold a clamp, tie a knot, or position a self-retaining retractor. Residents and senior medical students are delighted to be able to parrot such exercises for their juniors. With reading and thinking, and after taking others through the exercise, they usually end up understanding the problem far better than if they tried to puzzle it out by sitting down with the chapter. Why? Because the question has already been posed by a role model who has established its importance. In addition, teaching forces us to confront what we do not know, in order to give an explanation to someone who wants to know too. When senior medical students applying for residencies talk to me about the desire to teach, this is usually the kind of teaching that they mean. It is direct, personal, and fun. Moving beyond these individual exercises in improving the trainee’s base of knowledge, we also must think about the development of judgment and professional ethics. We want the resident to learn to ponder and then do “what is right.” To do this, we must talk about what decisions we make and why we make them. Out loud, we must talk about how we behave and why we behave that way . . . . Why do we insist that any imaging study— be it an endoscopy or a CT scan— be personally reviewed by the residents who are taking care of the patient? Why not just accept the report of the endoscopist or the radiologist? Why should we insist on obtaining and attending an autopsy on any patient who dies while under our care? Why not just make sure we hear about the result of the pathologist’s examination? The answers are self-evident, but not necessarily to the junior resident who has been up all night with 25 other sick patients. Now come the more uncomfortable questions: What happens if I the teacher also rely on the radiologist’s dictation and do not look at the scan myself? What happens if I could have made the time but chose not to attend the autopsy of a patient who died after an operation that I performed? The students and residents do not necessarily think this is okay. But if I do not show up, then the message to them is that one can get away with it. Go one step further: what is the message to students and residents if the attending surgeons, particularly the full professors or those in positions of leadership, do not regularly attend department conferences? What is the message to junior faculty if expectations of the residents are never earnestly discussed among the faculty as a whole? What is the message if each of the
DAVID I. SOYBEL: PRESIDENTIAL ADDRESS
faculty members is asked to spend 15 to 20 hours in the process of selecting residents for the training program, but is provided with no regular time to develop a consensus about how the residents will be trained. In order to expect exemplary behavior from the young, all of the citizens must set the example. Now, I am not going to swear that my leading thought every day is the best educational interest of the students and residents, even when they can be reconciled with the best interests of the patients. There are pressures to move things along and obstacles to finding time to do everything I should. It is hard to set the right example and it is hard just to try. But I would like to throw out a proposition and that is that the more that any one of us practices doing what is right, the more we tend to do it even when we are tired or distracted. In the Nicomachean Ethics [5], Aristotle said it this way: ethical or moral virtue (in Greek, ethike) is formed by habit (hexis). Doing the right thing . . . setting the right example . . . makes it easier to keep doing the right thing and to teach what is right. And so, when we talk among ourselves about doing what is best for the sake of the patient, and then do it, we are praising it not only to reinforce it for ourselves but so that the young will see that it is a good example to follow. That is why case conferences, particularly the M&M conference, are so important. Case conferences provide the opportunity for the community to praise good decisions and to explain disapproval of bad decisions. Likewise, participation in department meetings where curriculum is discussed is crucial. Such meetings develop consensus. Equally important, the discussion itself puts each of the participants on display for the others. My point is that talking the talk, if done in earnest and in public, will help you walk the walk. C. Becoming an expert. The types of experience, knowledge base, and skill sets needed to develop expertise as a top clinician, innovator, investigator, manager, or educator are certainly different. Nevertheless, one can make some generalizations about what it takes to make a name as an expert. One certainly must learn the common tools of the expert’s trade: knowing how to read the literature critically; learning what kinds of ideas work and how long it takes to get things done; learning how to summarize, analyze, and critique one’s own work; developing a style for writing and presenting short abstracts of promising work; and understanding the processes or peer review and institutional review of new projects or programs. However, the pathways to each form of expertise require a specific knowledge base, a unique skill set, and an opportunity to do something new and untried in a supportive environment. Depending on the kind of work involved, one may have to take advantage of many such opportunities, in order to be sure that the use of the tools has been mastered.
7
The process of becoming an expert takes time and this should not be surprising. After all, if it takes 5 years to become a responsible surgeon, it is not unreasonable to expect that it will take 5 years to become an independent investigator, a mature manager, or a skilled educator. And if such a long period is necessary, the budding expert must realize that the specialized training may only have begun during the 2 or 3 years traditionally set aside in residency for these activities. The remainder of time for development often must be negotiated as part of the first job, requiring time, space, money, a supportive environment, and a proper academic position. In addition to all this, however, most all of us would agree that the path requires a mentor. Recently, much has been said in our academic surgery circles about mentoring. But I would like to put my personal spin on the activity and the rewards of mentoring, as well as to talk about how it fits into to the overall education of an academic surgeon. Who was Mentor? In Homer’s Odyssey [6], Mentor is a trusted friend of Odysseus, left behind in Ithaka to look after the hero’s household and family while Odysseus has gone off to fight the Trojans. After 20 years, however, Odysseus has not yet returned. His household and property have been defiled by suitors to his wife, and Mentor has been powerless to protect them. Interestingly, the actions that define the word “mentor” are not his at all. In fact, it is Athene, the goddess of wisdom and war, who, taking on the likeness and the voice of Mentor, becomes a guide and friend to Odysseus’ son, Telemachus. Telemachus is just coming of age. He has a noble heritage and the right aspirations—to seek out news of his father and to restore order and dignity to the household. But he does not know where to look for his father and he does not know how to take his place in the world. What does Athene, in the likeness of Mentor, do for Telemachus? First, she sees him for who he is, but she can also see ahead to what he can and should become. She asks him uncomfortable questions, all boiling down to one: does he have the right stuff? Her first action is to show him his own internal confusion. Only then does Athene-as-Mentor help him understand what he must do and that he must leave home. She herself then organizes his provisions, companions, and the ship that will see him safely away. Throughout the trip, she plays the role of counselor, advising Telemachus which of the great heroes of the Trojan war he should visit and how to speak with them so as to reflect honor on himself and his father. She points out what his peers (i.e., Orestes) are doing in order to make a name for themselves. Athene-asMentor steps in only to provide advice and encouragement. In this story, she uses her divine powers to intervene only if his life is in danger.
8
JOURNAL OF SURGICAL RESEARCH: VOL. 97, NO. 1, MAY 1, 2001
Over the years, I have thought about the meaning of this relationship between Athene-as-Mentor and the son of Odysseus. At first glance, it seems so straightforward: she shows him the opportunities and organizes the resources and the environment. She encourages, cajoles, introduces him to the right people, and shows him how to network. She lets him work his journey through, basically on his own, unless something really bad is about to happen. At the end, his father is home; Telemachus has the virtues of the Homeric hero and is ready to take his place alongside his father. All this is what I think mentors should do for their prote´ge´s. But it has intrigued me: why couldn’t Mentor himself be the mentor? Why did it have to be Athene? Well, I am not sure. But as I reflect on my own experience as a mentor to some really terrific research fellows, residents, and students, it occurs to me that they helped me to become better than I had been. There is something wonderful, almost magical, in watching them do things I cannot and yet knowing that they need me to be there to watch out for them, to guide them, and to be proud of their accomplishments. And, in reflecting on this privilege, I am tempted to conclude
that it was not that Athene turned into Mentor; rather it was Telemachus who made it possible for Mentor to have a share of the divine. And in the sense that being a mentor helps us to become wiser and better than we could possibly have been before, helping a young, worthy individual to become one of us is the best education for each of us. REFERENCES 1.
2. 3.
4. 5. 6.
Redfield, J. The Aims of Education (address September 24, 1974). In The Aims of Education: The College of the University of Chicago. Chicago: Univ. of Chicago Publications Office, 1997. Pp. 169. Dickens, C. The Posthumous Papers of the Pickwick Club. Harmondsworth, Middlesex, UK: Penguin, 1977. Chap. 20. Rutkow, I. M. The origins of modern surgery. In J. A. Norton, R. R. Bollinger, A. E. Chang, S. F. Lowry, S. J. Mulvihill, H. I. Pass, and R. W. Thompson, (eds.). Surgery: Basic Science and Clinical Evidence. New York: Springer, 2000. Pp. 3. Bloom, A. The Closing of the American Mind. New York: Simon & Schuster, 1987. Aristotole. Nicomachean Ethics. [Translated by M. Ostwald]. Indianapolis: Bobbs-Merrill, 1962. Book II, line 18. Homer’s Odyssey. [Translated by R. Lattimore]. New York: Harper and Row, 1967.