Setting standards of efficiency

Editor’s note:  This essay is part of a series of historical vignettes that the Bulletin is publishing as part of the regular “From the Archives” column. These brief articles center on key individuals and events in the history of the American College of Surgeons (ACS) and are written by members of the ACS Surgical History Group, chaired by ACS Past-President LaMar S. McGinnis, Jr., MD, FACS.

Franklin H. Martin, MD, FACS, acting as the General Secretary of the ACS, gave a talk to the Fellowship titled Problems of the College at the annual meeting of Fellows in October 1916, four years after the organization was founded. The following is a brief excerpt from that presentation:

But we are face to face with grave problems. Let me enumerate some of them: First, the discrepancies in the standards of efficiency among hospitals in which recognized leaders in surgery do their work. Second, the wide range of difference[s] in surgical training of graduates of medical schools of like classification. Third, the great difference in the surgical training received by intern[e]s in hospitals of comparable equipment. Fourth, the confusion in estimating the value of an assistantship to recognized surgeons. Fifth, the lack of a standardized system of case-histories through which we may estimate the merit of work as submitted by candidates to the Committee on Examinations. Sixth, lack of uniformity among graduate courses in surgery as offered by educational institutions which control the great clinical centers.*

The “efficiency movement” was central to the Progressive Era of the early 20th century. Waste, inefficiency, and incompetence festered in hospitals and the medical education system, weakening the effects of the modernization that was occurring in surgery. Dr. Martin and others believed that standards of efficiency were needed to elevate the quality of surgery and surgeons. The variance in quality among hospitals, the surgical training of medical students and surgical interns, assistantships, and postgraduate courses in surgery responsible for inferior surgical care could be eliminated by setting standards. Even the systems for writing, submitting, and evaluating the 50 case histories required for admission to the College needed standardization so that better judgments could be made regarding the admittance of Fellows.

The first standardization programs

College leaders quickly responded to these inefficiencies by establishing the Hospital Standardization Program, which created standards and required hospitals to meet them. This program lives on through The Joint Commission.

The American Medical Association (AMA) stepped in to create standards for internships in 1920, and both the College and the AMA set standards for residency programs in the 1930s—programs that continue through the Accreditation Council for Graduate Medical Education. Standards for individual physician competency were established through the certifying boards, beginning in 1916 with the American Board of Ophthalmology. Today, there are 24 certifying boards, and they also establish standards for continuing competency through their Maintenance of Certification programs.

The College’s response to Dr. Martin’s frank assessment led to the high standards with which surgery is practiced today. And the efficiency movement lives on, with many organizations and the government now setting standards for care and how medicine should be practiced. Standards of efficiency are now so ubiquitous that health care policymakers and the profession are confronted with the need to support standards that actually improve care, while casting aside those that make us wasteful, less efficient, and do nothing to improve care for our patients.

*Martin FH. Report of the General Secretary. Bull Am Coll Surg. 1916;2:18-26.

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