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Crisis in Health Care
February 2001

Impact on the New Chair

Author Affiliations

From the Department of Surgery, Oregon Health Sciences University, Portland, Ore.

Arch Surg. 2001;136(2):165-168. doi:10.1001/archsurg.136.2.165

Since World War II, multiple changes have occurred in medicine that are now affecting academic health centers and department of surgery chairpersons. None of these changes by themselves were intended to adversely affect department of surgery chairpersons, but the sum total effect constitutes a negative external force. In addition, there are internal forces in the schools of medicine and university hospitals that may negatively affect department of surgery chairperson in fulfilling the stated goals of excellent patient care, teaching, and research. Many of the problems brought about by these negative forces cannot be solved by a single department chairperson. However, individual department chairs can contribute to the solution by returning to the values taught to them by the role models of their surgical training.

I would like to take the liberty of rephrasing the title of this article to, "Is Being a Department of Surgery Chairman Fun?" The answer to this question is no. Is the job doable? The answer is yes. Although it varies from month to month, there are approximately 40 open chairs of departments of surgery across the United States. This relatively large number may be partially explained by a whole generation of surgeons—my generation—retiring at the same time. I believe that some of these individuals are stepping down early because of dissatisfaction, and the number one reason for so many open chairs is probably that the job is perceived as undoable. I believe it is important for the reader to understand why we are where we are, and I will use myself as the case history.

Decision nodes in a surgical career

When I began medical school, I had come from a very small (population 500) town in eastern Washington. My dream was to become a general practitioner and return to this small town to spend the rest of my life practicing medicine. In medical school, my role models were Robert Petersdorf, MD, and Clem Finch, MD, both internists. I thus made a decision to pursue internal medicine as a career, but during my senior year, I became disenchanted because I did not enjoy treating chronic disease, and I had enjoyed my surgical rotations. I then made my first important decision and elected to do a rotating internship at the University of Oregon, Portland, under J. Engelbert Dunphy, MD. Within 2 months of starting my internship, I made a decision to stay in surgery and to have Dunphy as my mentor. Toward the end of my internship, I was drafted into the United States Army, and after spending 2 years on active duty, I joined Dr Dunphy at the University of California, San Francisco. Early in my chief residency, I had another important decision to make: academic medicine vs private practice. I chose academic medicine for several reasons, the primary one being intellectual stimulation. I enjoyed teaching, and I had excellent role models throughout my residency, including Drs Dunphy, Blaisdell, and Wylie. All 3 exhibited the values and qualities that made the profession of medicine so attractive to me. It also taught me the importance of positive role models.

After spending the next year with Tom Shires, MD, another role model, at Southwestern Medical School in Dallas, Tex, doing a National Institutes of Health (NIH) special fellowship in trauma, I returned, by choice, to San Francisco General Hospital (SFGH) in California to start my academic career. San Francisco General Hospital was a perfect laboratory for teaching surgery. The surgery department was divided into 3 services: trauma or emergency, elective, and dirty surgery. The trauma or emergency surgery service was the busiest, with approximately 1800 to 2000 admissions annually. Elective surgery admitted 900 patients annually, and dirty surgery admitted 1200 to 1500 patients annually. Dirty surgery comprised hand injuries, burns, and infections. The chief resident on dirty surgery was a third-year resident, and this was the first opportunity to assert oneself and develop leadership skills. The surgical pathology of the patients at SFGH was truly remarkable, primarily because there were so many immigrants to the community, and we were their only resource for health care. Although Titles 18 and 19 had been passed in 1966, SFGH was still the "county" hospital. We were paid a very modest salary and assumed the majority of teaching of the University of California, San Francisco's surgical residents and medical students. Under Dr Blaisdell's leadership, we were able to get NIH funding for research, and overall, it was a very productive time in my early surgical career.

The last decision node that I made regarding my career was whether to be a department chairperson or not. At the time, it was actually a fairly easy decision. I had certain ideas on surgical education that I wanted to explore and perfect. I did not want to be a caretaker. I wanted to take a department in the doldrums and build it. I wanted to create a scholarly environment with excellent patient care as a base, where the faculty could serve as role models, much like those that I had worked with during my residency. I also wanted to emphasize that surgery is not only curative in some diseases but should improve the quality of life. Thus, I was probably no different from any other surgeon at that time who wanted to be a department chairperson. The desire was to establish centers of excellence where patient care, teaching, and research were the 3 pillars of a strong academic surgical department.

The first 7 years

In retrospect, it is hard for me to believe how naive I was at the time of negotiation with the dean at Oregon Health Sciences University, Portland, in getting the resources necessary to build a strong surgical department. I had been promised 5 new full-time equivalents ($40 000-$60 000 each). I had negotiated some research space and some endowment dollars for start-up costs in research. What I had not anticipated was the additional dollars it takes to recruit faculty and to front-end load them. In the year prior to my taking over as department chairman, the general surgery division at Oregon (2 individuals) had billed and collected $88 000. During my first year, I put myself on call at the University Hospital, Portland, and at the Portland Veterans Administration hospital as often as I could afford to. I was then able to build up a dowry for recruitment using these professional fee dollars, and start the recruitment process. Fortunately, I was able to recruit excellent people who, as I did, believed that it was important to reinvest in the department, not only from the standpoint of a workforce, but also with regard to research and educational programs. The size of the department doubled, and the quality of the residents made me swell with pride. This was pure fun.

The last 7 years

I will refer to the last 7 years as the era of discontent. The forces that brought this dramatic change in academic medicine began shortly after World War II and are beautifully articulated by Ludmerer.1 Subsequent recent editorials have also focused on the seminal events leading up to this era of discontent.2-5 I will give a summary of those events that I think were the most important for setting the stage for discontent and why.

In the 1950s and 1960s, the NIH expanded its research dollars, which in retrospect, may have been detrimental in 2 different ways. The first is that this growth allowed medical school faculties, particularly in nonsurgical specialties, to expand and even double or triple without a concomitant commitment to teaching or supervised patient care. The second adverse effect was paradoxical: the knowledge that came from the research led to newer diagnostic and therapeutic modalities that were extremely expensive.

The second seminal change in American medicine was the passage of the 1963 Health Professions Educational Assistance Act, with additional bills in 1965, 1968, and 1971. This led to an increased number of medical schools and expansion of medical school class sizes. The subsequent increase in doctors has been argued by Lewis6 to directly parallel the increased costs in medical care.

The third force was the passage in 1996 of Titles 18 and 19. The elderly and some of the indigent were now covered by health insurance, and academic health centers (AHCs) again increased faculty sizes.

It was in the late 1980s that possibly the most important change in academic health centers began to play out. The cost of medicine had reached a crisis for the business community. Total payroll costs were climbing, and private employers could not raise an employee's take-home pay. The business community responded by embracing a concept suggested a decade earlier by health economists: fierce price competition among insurers who then proposed externally "managed care" to physicians and hospitals.4 This concept was brought forward by the new Clinton administration in 1993 and championed by Hillary Clinton at the Jackson Hole conference. Ultimately, this proposal did not succeed, due in no small part to the arrogant approach of Mrs Clinton in leaving out of the planning process the very provider groups that would have to care for the patients. Nevertheless, the concept of managed care survived and was now pushed forward on an unsuspecting public and academic health community. As a result, AHCs adopted corporate strategies to cope with market forces, and they began losing sight of their basic mission, and therefore, their special place in society.2

Although these external forces set the stage for the era of discontent, there were forces within the academic health centers that also contributed to this discontent, particularly in departments of surgery. Poorly conceived managed care contracts led to decreased reimbursements to the AHCs. What better way to respond than to increase volume, particularly in the operating room. As a consequence, academic departments of surgery are now being held responsible for making up the shortages in reimbursement and operating costs. In some AHCs, the department of surgery operative volumes has doubled with profound negative effects on scholarly activity.

In the struggle to find solutions for poor reimbursement and strategies to counter managed care, the chief executive officers of hospitals, deans, and leaders within the institutions have turned to the organizations representing academic health centers: the American Association of Medical Colleges (AAMC), the Association of Academic Health Centers, and the University Hospital Consortium (UHC) to name a few. Many of the strategies developed by these organizations to counter managed care have no proven efficacy and may be harmful directly and indirectly to departments of surgery and patient care. For example, some of the bad investments made by AHCs have been to develop programs in primary care, and even to buy primary care practices. Traditionally, AHCs have not been leaders in primary care, and their true focus has been in tertiary care. Most of these investments in primary care have been significant money losers (millions of dollars), thus decreasing dollars available to invest in expanding, traditional tertiary programs. Academic Health Centers have bought community hospitals as "feeder" hospitals to provide tertiary patients to the AHC. Most of these ventures have failed: the UCSF Mt Zion debacle being a case in point. Another example is the investment of dollars in hospitalists and intensivists. The nonsurgical specialties have not provided supervision of house staff, and they have not met HCFA payment guidelines. To fix this problem, hospital administrators have hired hospitalists to provide house staff supervision. Similarly, we now see the emergence of not only hospitalists but intensivists, which in many institutions are an anathema to most surgeons since the Surgery Residency Review Committee still maintains that surgeons should provide global care. Other programs advocated by UHC and AAMC include centralization of practice plans, conversion to 501(c)3 status, and centralized billing systems, none of which have strong evidence to support them. Another irony is that the leadership within UHC and AAMC comes from the nonsurgical specialties that consume most of the resources in the AHC. Surgery is conspicuous by its absence. The most detrimental aspect of managed care within the hospital of an academic health center is probably that there is no longer any protected time for scholarly activity for surgeons.

I think it is fair to say in this era of discontent that the school of medicine (SOM) is also perceived as a negative force for most departments of surgery. In the last 14 years that I have been chairman, SOM resources have actually gone down, which has led to a decrease not only in dollars, but in support for the full-time equivalents that are necessary to accomplish SOM goals. Despite this decrease in dollars from the SOM, work has actually increased. At my own institution, the department of surgery took over the teaching of gross anatomy 9 years ago. This was primarily because the basic science department responsible for it was not doing a good job, and this was reflected in the Part I National Board of Medical Examination results. This intensive 9-week course taken during the fall of the academic year was taught by the department of surgery faculty with no increase in full-time equivalents or monetary reward.

Other forces within the AHC that negatively effect surgery include the balkanization that continues within the departments. Specifically, former divisions are forming their own departments, particularly in orthopedics, neurosurgery, and otolaryngology. Some of their professional societies have made it impossible to recruit to a division unless the demand for departmental status is met. The same subspecialty surgeons have dramatically increased their income during the past 10 years in academic departments, and instead of being a corporate model, we are rapidly approaching a "professional athlete" model. It has become extremely important for hospital success, as measured in hospital revenue, that the specialty surgeons be in the operating room as much as possible; even to the detriment of teaching, research, and resident supervision. The same surgical specialists do not want to take care of nonoperative cases, which are abandoned to the general surgeons.

Advice for the new chairman

Ludmerer's book, Time to Heal, may well end up having more of an effect on academic medicine than the Flexner Report.1 His book and the subsequent various editorials suggest that there are political, social, and economic models that are needed for solutions to the discontent in AHCs. I am somewhat skeptical. I think the very fiber of medicine (surgery) needs to be changed. I believe that the new chairperson of a department of surgery must be a positive role model. First and most importantly, the department chair must be a role model in patient care. The department chair has to be actively involved in patient care and in the operating room, otherwise, credibility with medical students and residents is lost. The department chair sets the tone for compassionate and appropriate care. There are some diseases and human conditions for which surgery is not indicated. We should not extend suffering. If we cannot cure the patient, we should focus on the remaining quality of life.

The second area in which the new chair must be involved is education. For the medical student or resident, this should be education in small conferences, at the bedside, in the intensive care unit, and of course, in the operating room. A chairperson's demeanor and behavior in the operating room is the model for the rest of the faculty. Similarly, the new chair must be a leader in research and optimally continue his or her laboratory or clinical research. If the chair is lucky, he or she will continue to be productive. If not, he or she has satisfied their curiosity, stimulated their own intellect, and served as a role model for the faculty.

The fourth area in which a chair must be a role model is compensation. By being fair and avoiding greed, hopefully he or she can take some of the dollars earned in professional fees and reinvest them in education, research, and new faculty.

The fifth area in which a chair must be a role model is in the realm of family, extramural medical, and nonmedical activities. One should save time for family and a hobby or outside interest, which will be intellectually stimulating in ways different from medicine.

If one is an excellent role model for the faculty, it will not necessarily solve the discontent that currently exists in academic health centers, but it will make the job doable. The solution to managed care and the external forces troubling academic health centers are probably found in the book Time to Heal and in the editorials listed above. As a department chairperson, one has to provide the leadership to lead the department in the appropriate way within an academic health center, but first and foremost a department chair must be a positive role model.

Corresponding author: Donald D. Trunkey, MD, Department of Surgery, Oregon Health Sciences University, 3181 SW Sam Jackson Park Rd, Portland, OR 97201-3098 (e-mail: trunkeyd@ohsu.edu).

Ludmerer  KM Time to Heal: American Medical Education From the Turn of the Century to the Managed Care Era.  New York, NY Oxford University Press1999;
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