Surgical Education Week

15 April 2008

Toronto

“People need to be reminded more often than they need to be instructed.”

Dr. Johnson

The Hopkins Years

George Zuidema

Dick Kieffer

Tom Gadacz

The Vanderbilt Years—the 1990s

John Sawyers

Walter Merrill

Wright Pinson

Jim O’Neill, Jr.

The Vanderbilt Years-2000s

Jeff DattiloDan Beauchamp Naji Abumrad

Disclaimers

No commercial interests.

No off-label uses recommended for pharmaceuticals or devices.

No base pair substitutions or p values.

Non-linear and a bit hyperkinetic.

“What Business Are We In?”

Surgical Education WeekWednesday

16 April 2008Toronto

Past APDS Presidential Addresses

• 2007—Jim Valentine: The Neglected Specialty• 2006—Joe Cofer: This Is Not your Mother’s APDS• 2005—John Potts: Dawn—of a New Day in Surgical Education• 2004—Richard Welling: The Evolving Renaissance in Surgery Education• 2003—Tom Whalen: Forgive and Remember While Punching the Clock

“The primary purpose of residency is the education of the resident, not service to the hospital.”

Frank Spencer, NYU. 1992.

Program Director Job Description

Dickens: “The best of times, the worst of times.”

Schizophrenia

The PD job is a lot harder in 2008 than in 1995.

Management vs. Labor

Resident as Ping Pong Ball

PDACGME

RRC/ABS

Attendings

& Chiefs

Q: What is the biggest problem, challenge in your program?

AAMC Chief Medical Officer-Group on Faculty Practice

3 Nov 2007 Washington DC

A: Increasing the professional behavior of our faculty.

Universal Access to Health Care

“The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide

enough for those who have too little.”

F. D. Roosevelt Memorial Washington DC

IOM: Disparities of Care

National

Global

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care--2002

Four Major “Surgical” Challenges Globally

Safe airway and anesthesia management

Trauma3: prevention; Rx of long bone fractures, spine and head trauma, burns

Ante-natal and peri-natal care; women’s health issues

Analgesia—peri-operative pain management; palliative care

Chyrurgerie is an art, which teacheth the way by reason, how by the operation of the hand we may cure, prevent and mitigate

diseases, which accidentally happen upon us.

Ambroise Pare, 1582

“Everybody, sick or well, is affected…by the material and spiritual forces that bear on his life…for the secret of the care of the

patient is in caring for the patient.”

Francis W. Peabody JAMA 88:877-882, 1927

To heal a person,one must first be a person.

Abraham Joshua Heschel“The Patient as a Person”The Insecurity of Freedom. Farrar, Strauss & Giroux. 1966.

Three Points

I. General Surgery

II. Surgical Formation

III. Sociology and Surgery

General Surgery and Its Iterations

Important, Meaningful

Workforce Projections = Job Security

Remuneration

A Longitudinal Analysis of the General Surgery Workforce in the United States,

1981-2005

Decline in # of general surgeons by 26% over the past 25 years

7.68 per 100K 1981

5.69 per 100K 2005

Lynge et al. Arch Surg 143:345-350, 2008.

Income: Medicare 30-Year ImpactYear Average Physician

Income

1966 $28,000

1970 $41,800

1975 $56,400

1982 $100,000

1997 $199,600Rothman, D.J. Money and Medicine: What Should Physicians Earn/Be Paid? Eli Ginzberg, The Economist as Public Intellectual, Horowitz, I.H. (ed), 2002, Transaction Publishers, New Brunswick, pp. 107-119

2005 General Surgeons ~$300k (ACS)

II. Surgical Formation

The growth and development of the whole person by an intentional focus on one’s (1) spiritual and interior life, (2) interactions with others in ordinary life, and (3) the spiritual practices (prayer, the study of scripture, fasting, simplicity, solitude, confession, worship, etc.).

“Spiritual formation …includes educational endeavors as well as the more intimate and in-depth process of spiritual direction.”

Gerald G. May, Care of Mind, Care of Spirit. HarperOne. 1992.

Spiritual Formation

Career vs. Vocation

Carrera. Latin for racetrack. car, career

Vocatio, from vocare, to call. “Calling, that whereunto God hath

appointed us to serve the common good.”

William Sloane CoffinA Passion for the PossibleWestminster/John Knox Press.

1993.

Prior Model of Education

See one, do one, teach one.

Learn by osmosis:

“Follow me around for five years, watch me; you will learn something.”

The curriculum is what walks in the ER door.

Tim Flynn, UFla.

New, Emerging Model

Intentional

Standardized

Work hours compliant

Out of OR technical skills acquisition:

Skills Labs, Simulation

Curriculum-based objectives

Competency-based goals and expectations

Surgical Formation:Intentional and Reflective

Industrial Model Formation ModelShow up on time Ongoing, continuous

acquiring

Pay attention Journey, not a destination

Hierarchy Team sport

Teacher > Student Co-learners

Fixed Period Lifetime process

Cantaloupe: Grape Process, not an event

Aschenbrener

“Education is not filling pails;it is lighting fires.”

 William Butler Yeats

1865-1939, Irish Poet and Dramatist1923 Nobel Prize for Literature (Poetry)

OBurns

Head: Cognitive, Judgement

Hands: Technical

Heart: People Skills, Respect

Health: Lifestyle

III. Sociology and Surgery

100 Years of Surgical Education

1910 Flexner Report

1964 Medicare

2003 ACGME Resident

Work Restrictions

1960s Women’s Liberation

Abraham Flexner

1964

Vanderbilt Medical School 1966

54 Students entered in the class of 1970

3 women, one of whom changed to PhD after one semester and married

1 Black—Vanderbilt’s First

1 Sri Lankan

49 White Guys

Surgery, Hopkins, July 1970

Pyramid

No SICU

No CT

No Laparoscopy or MIS

No Women

One Black

Baltimore, July, 1970

Hopkins Surgery 1977

1976-1977 Surgery Interns JHH

Alex Shepherd—PD, Henry Ford

Jim Sitzman—Former Chair at Georgetown and Rochester, now at Indiana U

Linda Reilly—First Woman ACS

Halsted Resident in 1981-1982

Program Director, UCSF

Chair, Surgical RRC

Linda Reilly, MD

Baptist Medical Centre

Ogbomoso, Nigeria 1978-1993

Nigerian Surgeons

JK Ladipo

Akin OlaOlorun

Wole Adebo

Layi Adeoti

M T Shokunbi

Proportion of Medical Students Who Are Women, 1965–2006. Data are from the Association of American Medical Colleges.Becoming a Doctor, Starting a Family — Leaves of Absence from Graduate Medical Education. R. Jagsi, N. J. Tarbell, and D. F. Weinstein. N Engl J Med 357:1889-1891,2007

Women in General Surgery Residency

30 to 25%

“Challenges confronting female surgical leaders: overcoming the barriers.”

PerseveranceDriveGood Communication SkillsA Passion for ScholarshipA Stable Home LifeA Positive Outlook

Souba, WW. J Surg Res 132:179-187, 2006

Lauren Nicolle

Lauren, Rebecca, Jay

Kilyn and Conner

Miller, Kai, Keller

Christopher, Nia, Tia

Chief Class of 2005

About Two Weeks Ago

Tuesday, 1 April 2008

Surgery: a Noble Profession in a Changing World

Women: 27.4% workforce in 1950s

44% workforce in the 2000s

Haile Debas. Ann Surg 236:263-269, 2002

American Surgical Association Presidential Address

Pregnancy, Parenthood and Family Leave during Residency

90% male MDs marry

70% female MDs marry

90% marry professional men

50% dual-MD marriagesMR Lewin, Ann Emer Med: 41:568-573, 2003

(But 100% are members of a family.)

A Longitudinal Analysis of the General Surgery Workforce in the United States,

1981-2005

Decline in # of general surgeons by 26% over the past 25 years

7.68 per 100K 19815.69 per 100K 2005

Women disproportionately concentrated in urban areas

Lynge et al. Arch Surg 143:345-350, 2008.

Work Activity in Pregnancy, Preventive Measure, and the Risk of Delivering a Small-for-Gestational

Age Infant

The risk of having a SGA infant increased with:• Irregular or shift work• Night hours• Standing• Lifting loads• Noise• High psychological demands combined with low social

support

A Croteau, S Marcouy, C Baisson. Am J Pub Health 96:846-855, 2006.

“Preeclampsia Sucks.”

A threat to the mother > the child.

~ 18%of maternal deaths in the US are related to preeclampsia or eclampsia.

HELPP: Hemolytic anemia

Elevated Liver Enzymes

Low Platelet Counts

Becoming a Doctor, Starting a Family — Leaves of Absence from Graduate Medical

Education

> Parenting during training> Child care> Parental leave> On-site child care R Jagsi, NJ Tarbell, DF Weinstein. N Engl J Med 357:1889-1891, 2007.

(SMNC Club—Bill Riordan)

Surgery: a Noble Profession in a Changing World

Women: 27.4% workforce in 1950s 44% workforce in the 2000s

Women physicians as a group average 20% fewer work hours than men.

Haile Debas. Ann Surg 236:263-269, 2002American Surgical Association Presidential Address

Effects Have Causes

Women carry the burden of child and aging parent care.

Affordable societal, institutional support for child and elder care is not available.

Self-Examine

PDs heavily depend on others, almost all women, to accomplish our tasks:

Spouses

Coordinators

Administrative Assistants

It takes about six women to keep ‘the tarp’ afloat!

Doris Risley

Vanderbilt Coordinator 1993-2005

Stephanie Rowe Alli Watts

The Vanderbilt Surgical Education Team

Deborah Greene and Remona Weakley of the Nashville VAMC

"For a woman to get half as much credit as a man, she has to work twice

as hard and be twice as smart....

fortunately, that isn't difficult."

Charlotte Whitton, the first woman mayor of Ottawa.

Σ = Three Challenges

Access to decent health care for all of our citizens.

Access globally to safe basic surgical care and anesthesia/airway management.

A supportive environment for our students, residents, and attendings for parenting, child care, and pregnancy. Our PD turf.

What Mentors Do

• Motivate• Empower and encourage• Nurture self-confidence• Teach by example• Offer wise counsel• Raise the performance bar• Shine in the reflected light “Mentoring young academic surgeons, our most precious assets.” W.W. Souba, J Surg Res 82:113-120, 1999.

24/7 Child Care for Our Residents

Toyota can do it – since 1993(http://www.pbs.org/wnet/moneyshow/cover/011201.html ).

Why not the American Surgical Community?

and Faculty, etc

IRB: “Assessing the Need by Residents, Resident Spouses, and Medical Students of Additional Institution-Based Child Care Services” Kyla Terhune, PI, Vanderbilt

Rick Keuler, Kyla Terhune, & Tate

Challenge

Instead of dreading and lamenting pregnancy or good parenting, let’s rejoice, encourage, and facilitate our residents being the complete individuals our patients and society deserves.

Let’s create systems to support our surgical progeny.

Let’s seize the high ground and advocate for family-, child-friendly surgical residencies.

So, What Business Are We In?The People Business:

Our Families

Our Colleagues

Our Patients

Our Students

But Especially Our Residents

and Their Families

“Preparing the surgeons of tomorrow to provide excellence in patient care.” APDS motto