Transcript Surgical Education Week: APDS

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
Dick Kieffer
George
Zuidema
Tom Gadacz
The Vanderbilt Years—the 1990s
John Sawyers
Walter Merrill
Wright Pinson
Jim O’Neill, Jr.
The Vanderbilt Years-2000s
Dan Beauchamp
Naji Abumrad
Jeff Dattilo
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 Week
Wednesday
16 April 2008
Toronto
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
PD
ACGME
RRC/ABS
Attendings
& Chiefs
Resident as
Ping Pong Ball
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
Unequal Treatment: Confronting Racial and
Ethnic Disparities in Health Care--2002
National
Global
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 Impact
Year
1966
Average Physician
Income
$28,000
1970
$41,800
1975
$56,400
1982
$100,000
1997
$199,600
Rothman, 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
Spiritual 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.
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 Coffin
A Passion for the Possible
Westminster/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 Model
Show up on time
Pay attention
Hierarchy
Teacher > Student
Fixed Period
Cantaloupe: Grape
Ongoing, continuous acquiring
Journey, not a destination
Team sport
Co-learners
Lifetime process
Process, not an event
Aschenbrener
“Education is not filling pails;
it is lighting fires.”
William Butler Yeats
1865-1939, Irish Poet and Dramatist
1923 Nobel Prize for Literature (Poetry)
O
Burns
Head: Cognitive, Judgement
Hands: Technical
Heart: People Skills, Respect
Health: Lifestyle
III. Sociology and Surgery
100 Years of Surgical Education
1910
1964
2003
Flexner Report
Medicare
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.”
Perseverance
Drive
Good Communication Skills
A Passion for Scholarship
A Stable Home Life
A 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 marriages
MR 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 1981
5.69 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, 2002
American 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
and Faculty, etc
Toyota can do it – since 1993
(http://www.pbs.org/wnet/moneyshow/cov
er/011201.html ).
Why not the American Surgical Community?
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