Eastern Virginia Medical School (Norfolk) students entering surgery. Reprinted with permission from Eastern Virginia Medical School's office of education.
Students seeking general surgery careers.1
L. D. Britt. "Halstedian 2" Residency TrainingBridging the Generation Gap. Arch Surg. 2002;137(3):271–273. doi:10.1001/archsurg.137.3.271
The turn of the century has brought more than a new millennium. It has placed a spotlight on a medical system in crisis. This has not been of sudden onset but an insidious process that has occurred during the last 2 decades for most of the nation. What makes the effect of this crisis so alarming is the fact that it emerged from what was considered a gilded era. A period of overall financial surplus and exponential growth had occurred in practically all aspects of medicine, with increased disbursement of direct and indirect medical expenses, expansion of clinical practices with unprecedented profits, increased medical school enrollment, an increase in the number of residents, and enhanced research programs. Concomitant with this phenomenon were skyrocketing medical costs. With these costs as high as 15% of the gross national product, the medical field became fertile ground for a multitude of managed care initiatives that often promoted goals in competition with the discipline of health care delivery. Many managed care ventures embraced a policy of proprietary issues ahead of service, in keeping with the business motto "There is no mission without a margin [profit]."
The contrast in values between the business world and the medical community was quite apparent: profit vs service advocacy; competition vs altruism; consumerism vs humanism. Strict adherence to the business model in the medical arena resulted in a long list of failures including health maintenance organizations, "purchase" academic institutions, and limited liability corporations. The prototypical case study of this reversal of fortune was at the Medical College of Pennsylvania–Hahnemann University in Philadelphia. The public backlash against the business of medicine has been stunning. Less than 10% of Americans expect managed care organizations to be ethical. Unfortunately, academic medicine has been a major casualty of this shift in emphasis toward the business model of medicine. Its 3 basic missions, clinical care, education, and research, have been strongly challenged by this change. The "drive-thru" medicine approach has not only shaken the infrastructure of academic medicine but has ushered in a culture change in the field, resulting in a perceived generation gap. This is quite apparent in the discipline of surgery. Whether or not there is a more causal relationship to the events noted previously is open to debate. The generation gap depicts a different work ethic, with career pursuits in medicine overwhelmingly influenced by lifestyle issues and financial concerns, resulting in an apparent decline in the best and brightest candidates entering general surgery. A less than subtle message, essentially confirming this fading appeal, was sent when 38 categorical positions went unfilled in the 1999 resident match results in general surgery. Even the staunchest optimist became alarmed on March 20, 2001, when 68 categorical positions went unfilled in 40 programs (Table 1). This is consistent with the decline in quality candidates pursuing general surgery training. At our institution, this precipitous decline is depicted in Figure 1.
This trend was documented almost a decade earlier by Kassebaum and Szenas (Figure 2).1 Several hypotheses have attempted to explain the decrease in surgery applicants, including an overaggressive generalist initiative, the gender factor, in which there has been an exponential increase in the percentage of female graduates and a relatively lower percentage of women seeking careers in general surgery, and financial concerns about the extended length of training and mounting loan debt. The problem is likely multifactorial and will ultimately need to be addressed using a multidimensional approach. With respect to surgical training, several questions are now being openly raised, including the following:
Has a career in surgery lost its appeal?
Is the lifestyle issue a "sacred cow"?
Is the quality of surgical residency applicants deteriorating?
Cofer et al2 addressed the last question.
Although the authors concluded that there was not a decline in the quality of the surgical residency applicants, the study was poorly designed, with less than optimal statistical analysis. The population of interest in the study included all 226 residency programs. The authors collected data on a sample of 90 programs, or 40%. The conclusion reflects an inherent selection bias; there is no reason to believe that the respondents to the questionnaire sent to the 226 program directors were of the same opinion as the nonresponders. This bias would affect all of the study's conclusions. With the presented sample size, the SE and other statistical computations would require the incorporation of a finite population correction factor. No attempt to do this was described in the article. Properly incorporating the finite population correction factor into statistical formulas would have reduced SEs, making the analysis more sensitive. Program directors' responses to 3 subjective questions were analyzed using t tests. A nonparametric technique such as the Mann-Whitney test would have been more appropriate considering the type of data (5-point Likert scale) being analyzed.
The results indicate that no statistically sound studies have challenged the perception that the quality of surgical residency applicants is deteriorating, although the term quality must be more specifically defined. On the contrary, the rising number of unfilled categorical positions in general surgery and the relatively high attrition rate in these residency programs strongly supports this perception. In fact, individual programs along with several national organizations (including the Association of Program Directors) have begun to reevaluate graduate medical education in surgery. With William Halsted, MD, widely recognized as the pioneer of surgical residency training in this country, those in the field have begun to call for a "Halstedian 2" change to graduate medical education in surgery. Such a change would undoubtedly have to address several major challenges to surgical training, including (1) the limitation of resident work hours; (2) continuity-of-care issues; (3) specialty encroachment; (4) graduate medical education funding; and (5) competency assessment.
The Libby Zion case3 at New York Hospital (New York) sparked an ongoing debate about the need for drastic limitations on resident work hours. The subsequently established Bell Commission directed the officials of New York State to monitor resident work hours according to New York Health Code statute 405. This resulted in hospital inspectors being employed to conduct in-hospital surveillance in conjunction with substantial financial penalties for violators. With other states beginning to reassess resident work hours, this has become a major dilemma for program directors; some of the proposed limits are in gross conflict with the Program Requirements for General Surgery (section V.G), which state the following: "Graduate education in surgery requires a commitment to the continuity of patient care."
Although the Accreditation Council for Graduate Medical Education has cited programs that violate resident duty hours standards and the associated requirements, a more strict reduction in resident work hours (<90 h/wk with an increase in nonworking hours post-call) would inevitably put surgery training programs in harm's way. It would be difficult for any program to cultivate even a semblance of patient continuity. In addition, such a work hours limitation and the corresponding increase in off-duty hours would likely be prohibitive to achieving the educational goals and objectives of the training program. Whether or not adequate operative experience would be obtained will be yet another challenge, particularly in the current environment of specialty encroachment from nonsurgical disciplines. Success with closed interventions (vs an open, operative approach) has enticed many nonsurgical specialists to provide definitive care for patients who were traditionally treated by surgeons.
To accomplish all that is required to be a well-trained and competent surgeon, in an environment with steadily increasing technology and a public that understandably demands documented excellence and has essentially no tolerance for errors, will be a formidable challenge. It is unlikely and undesirable that additional months or years will be proposed to accommodate the growing requirements for training and the need to limit the weekly work hours. Even if such a proposal is endorsed, who will provide the additional graduate medical education funding? Most important, with an extended training period, how attractive will general surgery residency training be for potential applicants who are already burdened with massive school loan debt?
What happens to the research experience? With a new generation facing different challenges and having different expectations, the timing is right for a Halstedian 2 change. This will require multiple phases prior to its full implementation; however, the foundation, or matrix, for a successful transition includes 7 starting points, with the protection of the core values of surgical training the most paramount (Table 2).
Corresponding author and reprints: L. D. Britt, MD, MPH, Eastern Virginia Medical School, Department of Surgery, 825 Fairfax Ave, Suite 610, Norfolk, VA 23507 (e-mail: email@example.com).