Editor’s note: The following comments were received regarding recent articles published in the Bulletin.
Letters should be sent with the writer’s name, address, e-mail address, and daytime telephone number via e-mail to firstname.lastname@example.org, or via mail to Diane Schneidman, Editor-in-Chief, Bulletin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611.
Letters may be edited for length or clarity. Permission to publish letters is assumed unless the author indicates otherwise.
Response to “Have we drifted too far from the fundamentals of surgical training?”
As the 2018–2019 Chair and Vice-Chair of the American College of Surgeons (ACS) Resident and Associate Society Communications Committee, we thank Guy Voeller, MD, FACS, for his letter to the Editor published in the February 2020 issue of the Bulletin and appreciate the opportunity to respond.
We acknowledge that both surgical training and surgical practice have changed drastically in the past 30 years—not always for the better. We also recognize that, in some ways, surgical practice is more challenging than ever because patients are older, have more comorbidities, and take more medication. Patient care is increasingly complex, with greater specialization and the advent of electronic health records.
Surgeons have changed as well. Many of us expect some form of work-life integration, in part because of generational differences and in no small part because of the 80-hour workweek, which basically mandates that surgical residents train in a shift-based environment.
As Dr. Voeller mentions, the world in which we live and train also has changed. Although we would argue against his claim that “criticism, toughness, and total dedication are seen as evil,” we do agree that the expectation of civility among all members of the surgical team is the new norm. As new attendings, we have found that although the accepted form of criticism has evolved, the expectation of excellence is still deeply embedded in the surgical culture. For most of us, it is just as powerful to hear, “I’m disappointed,” as it is to be yelled at, thrown out of the operating room, or dressed down during a morbidity and mortality conference.
Furthermore, medical students and residents do have strong opinions about how they want to be taught. But can we blame this generation, which has literally grown up in front of computers, for wanting to learn differently than students did even 10 years ago? The way they express their dissatisfaction may need improvement, but the ability to recognize and articulate one’s needs is a core principle of adult learning.
The important question is whether any of these differences have changed the surgeon-patient relationship and the quality of surgical care?
Clearly, the surgeon-patient relationship has changed, and as more physicians become hospital employees, it will continue to shift. However, most surgeons who perform elective operations do not work in shifts.
As a foregut and bariatric surgeon, Dr. Johnson-Mann has what is considered an elective practice. She generally first sees her patients in clinic and has developed a relationship with them before the planned procedure. She is committed to her patients, on call or not. If any of their patients develop an issue that demands medical attention, she and her partners handle it. Every case stays on her mind long after the operation—critiquing the technique used and instruction to the residents, wondering if she would do anything differently next time. After discharge from the hospital, patients remain on her mind until they return for postoperative follow-up a few weeks later, and, depending on the operation, they remain in her thoughts for weeks or months afterward. If postoperative issues arise, as the surgeon, she feels obliged to manage them. Providing this care may conflict with her homelife, but her patients come first. Our generation’s priorities may differ from those of previous generations, but our dedication and commitment to patient care do not.
As an acute care surgeon, Dr. Hoffman’s practice does use a team-oriented, shift-based model, but she gives her cell phone number to her patients and encourages them to use it when they need her. She almost always is available to speak with them and to ensure they get the help they need. Furthermore, her partners almost always are accessible. This model requires constant communication between team members and with the family. When she sees a patient in the trauma bay or the emergency department, she explains that she is part of a large team of health care professionals, thereby managing expectations early in the relationship’s course. Life is all about trade-offs. Acute care surgeons and their patients have short-term relationships, but most patients in her hospital system benefit from always having both an emergency general surgeon and a trauma/critical care surgeon in house 24 hours a day. She chose this career path not because she didn’t want to provide continuity of care, but because she loves taking care of the sickest patients and prefers in-house call. Between operating, going to clinic, doing research, and constantly switching between days and nights, even this shift-based specialty lacks appeal for someone craving work-life integration.
Despite these changes in the surgeon-patient relationship, no data are available to suggest that the quality of surgical care has diminished.
Dr. Voeller claims we are falling “victim to the lowest common denominator” in the recruitment and training of residents. We find the opposite to be true. According to the 2018 National Resident Matching Program, the average Step 1 score for applicants matched in surgery was 236.* In 2009, the average score was 224.† Applicants appear to be more well-rounded as well, as evidenced by an increased percentage of applicants with peer-reviewed research, graduate degrees, and volunteer experience in 2018 compared with 2009. Residency applicants often are entrepreneurs, professional athletes, and so on. One could argue that pursuing interests outside of surgery could diminish the training experience, but we maintain that diversity of thought and experience makes the surgical profession better, more flexible, and equipped to tackle the demands of today’s world.
Times and priorities have changed, and surgeons today aim to take care of both their patients and themselves. With the ongoing flexibility of trainees, attendings, program directors, and hospital administrators, these dual objectives are achievable.
Melissa Red Hoffman, MD, ND
Crystal N. Johnson-Mann, MD
While I will agree that surgical training has changed somewhat, the day-to-day demands of being a good surgeon and what it takes to become a master surgeon have not. As someone who has been practicing for 33 years and does more than 750 major operations annually, I can promise you that despite young surgeons’ concerns for work-life balance and an 80-hour workweek, what it takes to be the best in this job has not changed. The inmates are running the asylum, and it is not a good blueprint for success. Naivety is no substitute for intense training.
To use the language of the respondents in the previous letter, I am disappointed that we have not mentored this generation of surgeons to be ready for practice and have instead left them in a haze of their own warped ideas about what life as a surgeon should be like. I am disappointed to know that their values will prevent them from becoming the best that they can be. I am disappointed that they think everyone thinks like them. Many residents wish they were released from the bonds of the 80-hour workweek, political correctness with regards to learning, and, yes, they wish to be freed from civility because they know that is not reality. Unfortunately, these throwbacks feel they have no voice in leadership, and so they are forced to conform to the lowest common denominator that some of their peers and the Accreditation Council for Graduate Medical Education promote.
Surgical residents have five to seven years to cram in as much knowledge as possible, so when they are let loose on the public, the harm they do will be minimized. Every second should be spent learning surgery. Nothing else. Unfortunately, they are being told the amount of effort they exert during training has no relationship to how they turn out as a finished product. The people they may harm in the next 15 years as they learn their craft are the guinea pigs and will pay the price. I see it every day.
Guy Voeller, MD, FACS
Defining surgeons’ value
I want to applaud Dr. Voeller for his letter in the February issue of the Bulletin about the quality of surgical training today. It was pretty bold of him to be frank in stating where he sees the quality of trainees going. It was also interesting that the ACS, with its predominantly academic leadership, published it. To me, it’s a signal that more open dialog may be coming.
My focus in writing this letter is on Dr. Voeller’s final point about surgical training being hard and not for everyone. It is not for everyone, and it is not easy. Not everyone can be spit out of the other side of surgical training and be competent, but most of us are. And not many people can save a person from a deadly injury or alleviate pain from a surgical condition, but we do. That to me is a testimony to our own individual integrity and our collective power. That is why our value must be reclaimed.
Many surgeons who post in the ACS Communities understand what the terms value, devalue, and revalue mean when talking about surgery, but some do not. Our value goes beyond what we are paid; it speaks to how we are treated. Do we have an equal voice to hospitals, insurers, or legislators? Do we have a place at the table, or are we simply collecting the scraps after the big kids’ party is over? Do we stand up for ourselves and, in so doing, for the patients to whom we administer our craft? These are all value, and I am sure many reading this letter will say, “Wow, we have lost that. We have.”
One of the areas where we can reclaim and redefine our value is in how we brand (or rebrand) ourselves. That means assigning some new terms to describe us and what we do. Hospitals do this all the time by associating with a larger system like the Cleveland Clinic, OH, or MD Anderson Cancer Center, Houston, TX. But we can do it more simplistically if we seize on what Dr. Voeller said in his original letter. We are medicine’s Navy Seal equivalents—an elite force.
We do things no other physicians can or will do. We do things other providers in the system cannot do. I use the term “definitive responders” to describe what we do because not only does it describe what we do, but it also fits into the overwhelming public support and admiration for first responders. Without us, where would first responders take the injured or ill? Think about that. Rebranding ourselves is one way to revalue what we do. Another is by speaking directly to patients, past, present, and future with statements that they can identify with: “We are the surgeons who save your lives and end your suffering day and night, weekends, and holidays.” And then add value to that statement by saying, “We stand with you against the corporatization of health care and how it has shifted resources away from the fundamental relationship of health care—the one between the surgeon and the patient.” Does that allude to the money side of value? You bet, but it also assures patients we give a hoot about them and the broken system they and we are all forced to function within.
The days of shrinking away from talking about money are over. Now we must talk about value—our value—and how it applies to the people we treat. We will never win any battles against the takeover of health care by the C suite or suits by remaining silent and being afraid of talking about how bad the system has become. It is how we talk about it that makes a difference. We are the Navy Seals of medicine. Let’s start by revaluing that.
Eileen Natuzzi, MD, MPH, FACS
ACS needs to act on climate change
The cover story in the September 2019 Bulletin was “Climate change and the future of surgery”—quite a provocative title. The seven-page article by Matthew Fox conveys how climate change will affect the health of our patients and lists the ways global warming may alter surgical practice. Mr. Fox goes on to describe efforts to “green the OR” and how hospitals can reduce their carbon footprint.
He mentions two groups that are confronting the problem: Health Care Without Harm invites individuals to join its Physicians Network, and the Medical Society Consortium on Climate and Health combines the forces of larger organizations to confront the matter. Last June, these two groups and others “came together to declare climate change a health emergency and called on policymakers to take steps to address it.”
The consortium has 23 component societies and numerous smaller affiliates. Among the societies are the American Medical Association and the American College of Physicians. The ACS has not signed on. Why raise the flag if you are not going to salute it? I hope that the Regents will decide that the ACS should become a member of the Medical Consortium rather than just relegating it to a passing mention in the Bulletin.
Edward Z. Walworth, MD, FACS
*National Resident Matching Program. Charting outcomes in the match: U.S. allopathic seniors. 2nd Edition. Available at: www.nrmp.org/wp-content/uploads/2018/06/Charting-Outcomes-in-the-Match-2018-Seniors.pdf. Accessed February 11, 2020.
†National Resident Matching Programs. Charting outcomes in the match. 3rd Edition. Available at: https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2013/08/chartingoutcomes2009v3.pdf. Accessed February 11, 2020.