Despite being written centuries ago, the Hippocratic Oath remains a relevant declaration for all entering into the hallowed field of medicine. Every year, medical students, upon receiving their white coats, recite that sacred promise, “to first do no harm.” And although this oath has become synonymous with the practice of medicine, perhaps less well known but equally poignant is the promise made further along in that pledge to “remember that I remain a member of a society, with special obligations to my fellow human beings.”1 This promise is a reminder of the responsibility that we as physicians have to advocate for ourselves, our peers, and our patients.
In modern medicine, this obligation has been borne out in a variety of fashions, particularly in the role of educating and teaching the next generation of physicians, which remains a key facet of this commitment. Beyond just the sharing of knowledge, our oath grants us with a responsibility to “those who are to follow” and is a commitment that, over the years, the medical community has embraced. From the very first apprenticeship to modern surgical residency programs, physicians have traditionally taken this duty upon themselves with our own set of internal rules and regulations. As the intersection between medicine, law, and politics continues to become more apparent, elements outside of medicine are progressively shaping the face of modern medical education. Although the outside perspective can be a welcome new voice in medical education, it is critical that physicians remain engaged and invested in this process, which is paramount to the future of the profession. The following is a review of the history of surgical education self-regulation, the systems in place today, and future opportunities for engagement.
Our history of self-regulation
In the era of modern medicine, surgeons have been an invested group of physicians keenly interested in the regulations and standards of their field, as demonstrated through numerous examples of self-regulation; the founding of the American Board of Surgery (ABS) in 1937 is a key example of this commitment.2 The ABS functions as a self-regulatory body, setting standards for training and board certification with the ultimate goal of protecting the public and the integrity of the specialty. These activities include reviewing time in training, breadth of experience, and number of cases, as well as the development and implementation of challenging written and oral examinations. Beyond initial certification, the surgeon also must complete Continuing Medical Education (CME) and recertification exams to maintain their board-certified status.3 Although these self-regulated certifications exist outside of any governmental regulating body, their validity and merit have made them requirements for many regional and state licensing bodies.
Similarly, the American College of Surgeons (ACS) has been at the forefront of ensuring quality care provided by competent providers. In the early 1900s, the ACS established some of the first standards for hospitals and house staff. Encouraging outcomes reviews and setting certain requirements for patient care, the College performed hospital site visits to ensure standards were met. The ACS leads the way in this quality regulation—so much so that in the 1950s what we now know as The Joint Commission was formed from these principles.4 The Joint Commission has transformed into the largest hospital-accrediting body in the U.S., with recognition from governmental regulating bodies.
Although these examples demonstrate the success of surgical self-regulation with respect to education and training practices, the field is increasingly encountering external pressures around standards and regulations. In 2005, the ABS recognized that knowledge and procedures change rapidly, and reassessment every 10 years was insufficient to address these gaps, so the organization shifted toward the Maintenance of Certification (MOC) program. In order to maintain board certification, the surgeon submits their professional standing, CME activity, practice assessment, exam, operative log, and reference letters. In 2018, ABS adopted a model of Continuous Certification in an effort to ensure greater flexibility and a practice-related focus. This restructuring changed the testing requirements to every two years, allowing surgeons to choose areas that are more relevant to their practice in addition to required core topics.5 Some state lawmakers, however, have passed legislation inhibiting MOC and, consequently, our profession’s ability to set its own standards and hold our peers to those standards.6
Other legislative interventions have affected areas such as physician payment, administrative burden, quality and patient safety, workforce shortages, and the practice of surgery. Health care policies will continue to influence surgical practice and training for years to come. As key players in these systems of care, we must be involved in the creation of the policies that continue to influence how the profession and surgical training are regulated.7
How politics affects work hours
Perhaps one of the most prominent cases of external advocacy affecting medical education is the effect of public pressures on the development of duty-hour restrictions for trainees. First introduced in 1889 by William S. Halsted, MD, FACS, the resident training system was a novel model requiring young physicians to devote the entirety of their time to their patients in order to acquire hands-on clinical training and operative skills. Duty hours were nonexistent. Over the course of the 20th century, the exploitation of trainees by health care systems, sometimes at the expense of patient safety, was widespread.
Perhaps one of the most prominent cases of external advocacy affecting medical education is the effect of public pressures on the development of duty-hour restrictions for trainees.
The Libby Zion case in the 1980s and the Bell Commission report in 1989 were pivotal societal calls for the development of duty-hour restrictions and increased educational regulations.8,9 The tragic case of Libby Zion, a young woman who died under the care of two overworked and overwhelmed residents, led to the Bell Commission report, which concluded that residents lacked proper supervision and introduced the 80-hour workweek.8,9 Public outcry was significant, but it was not until the Accreditation Council for Graduate Medical Education (ACGME) issued duty-hour restrictions in 2003 that these protections were formalized.
Going a step beyond changes born of public pressure and in addition to mandating educational interventions, the ACGME also sought to critically evaluate these changes and the impact they had on trainee education. Addressing concerns that limitations in training hours resulted in insufficient surgical training and skill development during residency, the Flexibility in Duty Hour Requirements for Surgical Trainees Trial was performed. A prospective, cluster-randomized, two-armed noninferiority trial, this study sought to evaluate the effect of increased duty-hour flexibility on patient outcomes, resident education, and trainee well-being. Ultimately demonstrating noninferiority to the standard duty-hour regulations,9,10 the involvement of physician advocates and critical review of policies implemented because of public pressures has helped to guide a national restructuring that serves the public interest and protects the educational integrity of the field.11 While this interplay of public policy and physician engagement has helped successfully adapt this area of training to more modern standards, several other fronts still exist in surgical training and education that require active physician participation.
National residency shortages
The Balanced Budget Act of 1997 capped the number of residency training positions funded by Medicare, despite projected shortages of more than 50,000 to 100,000 physicians by 2033.9,12 The coronavirus 2019 (COVID-19) pandemic shed light on the effects of these shortages, leading to the introduction of the Resident Physician Shortage Reduction Act of 2021. This legislation would expand the number of residency positions by 2,000 annually for seven years.13 Although the introduction of this bill appears to offer some hope for addressing workforce shortfalls, it is important to note that Congress has introduced this legislation six times in the last decade without any movement.14
Increasing the number of residency positions would not only improve the work environment and well-being of current trainees, but also would address the rising nationwide shortage of surgeons. Recent data project a shortage of up to 28,700 surgical specialists by the year 2033, which will especially affect rural areas, where only 8 percent of practicing surgeons provide care to 20 percent of the country’s population.15,16
One response to the surgical and medical workforce shortage has been the addition of advanced practice providers (APPs), primarily nurse practitioners, physician assistants, and certified registered nurse anesthetists. This increase in physician extenders has subsequently led to an increase in APP training programs.15 However, the number of residency positions has not proportionally expanded over this time frame.9 Furthermore, in the 2020 main residency match, more than 2,700 medical students applied for 1,536 categorical surgery resident positions, and the number of unmatched applicants likely will continue to grow as the number of medical schools increase.12 Expanding the number of categorical surgery residency positions will improve the dedicated education time and workload of current residents, the nationwide deficit of practicing surgeons, and the medical student match rate into surgery. Research also suggests that it is financially advantageous for institutions to increase the number of surgical residency positions, with a recent study demonstrating that the replacement of 30 surgical residents with APPs at a single institution would cost more than $1.5 million annually.17
The addition of APPs at academic institutions also has led to discussions regarding the impact these practitioners have on surgical education. Studies have shown that APPs can reduce workload, leading to increased dedicated education and time operating.18 Concerns also have been voiced regarding the division of training opportunities for residents with the increase of APPs, especially with regard to surgical procedures.18 As APPs are increasingly integrated into surgical training, physicians must continue to advocate for the creation of expectations and roles among residents of all levels and our APP colleagues.
If Congress cannot reliably address these vital issues, then it falls on the stakeholders to advocate for themselves. This movement has been demonstrated most aptly this past year by resident physicians advocating for improvements in their work environments. When Stanford University, CA, left residents out of its initial COVID-19 vaccine distribution plan, residents there wrote to leadership and gathered to demonstrate, which led to a public inquiry into the institution’s policies and resulted in vaccine distribution to all frontline workers.19
Implementing improvements for surgical training nationally requires time and organization. The stagnancy of the Resident Physician Shortage Reduction Act demonstrates that the future of surgical education is dependent on health care advocacy.
Similar advocacy by residents has occurred at various institutions in response to salaries that have inadequately accounted for inflation. Examples of this include advocacy from the University of Washington (UW) House Staff Association, Seattle, which took out an advertisement in the Seattle Times directly addressing leadership at UW Medicine to increase public knowledge of their working conditions.20 Both of these actions reached national news outlets, igniting conversations on the treatment of resident physicians.
Implementing improvements for surgical training nationally requires time and organization. The stagnancy of the Resident Physician Shortage Reduction Act demonstrates that the future of surgical education is dependent on health care advocacy. The resident-driven actions at Stanford and UW demonstrate that advocacy works, and the same momentum seen at those institutions must be applied to these ongoing issues. If surgeons and surgical trainees want to protect and expand graduate medical education, they must advocate for it.
Programs in action: Understanding health policy
Inherent to this call for engagement and advocacy is the need for education and understanding of how health policy is developed and implemented. Formalized advocacy education is slowly gaining favor, but knowledge and access, especially in surgery, is limited.21,22 Several curricula have been developed to address these knowledge gaps and rolled out at various levels, including national, institutional/departmental, and clinical interventions.
Though health policy is its own field, dual-degree programs—medical degree combined with master’s program in public health and business administration, as well as law—are viable options to obtain formalized education. Dedicated study time allows for the development of foundational skills and a career that centers on health policy issues. These programs, however, involve an application process, are typically expensive, and educate students individually. An alternative is fellowships and conference forums that focus on drawing together physicians with shared interests. The Heller School for Social Policy and Management at Brandeis University, Waltham, MA, hosts many opportunities ranging from weekend forums to weeklong workshops to educate physicians on health care policy basics, implementing efficient and sustainable service delivery, and guiding participation in policy reform. Although these events can be costly and inflexible in scheduling, the ACS has partnered with a number of institutions, including Brandeis, and other organizations to cosponsor scholarships that promote surgeon advocacy.23
On a more local scale, institutions have implemented departmental and multidisciplinary curricula. The department of surgery at Baylor College of Medicine, Houston, TX, developed a health care policy and management curriculum in response to their residents’ general lack of awareness about health care legislation and the business of medicine.22 Baylor developed a formal two-year curricula built into its existing didactic time in which local experts in a variety of fields volunteered to host grand rounds and small group sessions.22
George Washington University (GWU), Washington, DC, created a fellowship in health policy elective—a three-week intensive curriculum designed to expose residents to health policy issues in an effort to promote resident engagement and advocacy.21 For the GWU program, invited local presenters spoke on a variety of topics such as basic government structure, mental health, and global health. Both the Baylor and the GWU programs note that institutional/department buy-in and access to regional resources were instrumental in providing a diverse, robust, and honest education.
The clinical ward is an underrecognized area for learning about health policy. After every patient encounter, family medicine residents and students at the University of New Mexico School of Medicine, Albuquerque, evaluated the circumstances in which the patient presented and if community or hospital policies affected their condition.24 Each resident identified a personal interest, developed a project, and created actionable change in response to the encounter. This clinically driven culture shift made health policy education a daily intervention.24
Another organization, Socially Responsible Surgery (SRS), was built on the recognition that outcomes and disparities in access to surgery should guide conscious practice.25 With a focus on both education and implementation, this Boston Medical Center (BMC) Coalition has initiated various projects, such as the Community Violence Response Team and the BMC Preventive Food Pantry. The concept of “shared” advocacy takes it one step further by stating that the community determines its health care needs, and therefore, physicians should advocate with, not for, patients.
This approach is perhaps best demonstrated by the Communities and Physicians Together program, which partners pediatric residents at the University of California Davis with local communities. The curriculum requires residents to engage with their communities for an entire year prior to developing a collaborative project to improve community health.26 Even the simple change of involving a social worker on rounds can have lasting effects on educating providers of common resource limitations and local needs.24
Each of these curricula has its disadvantages. Often larger-scale curricula imply higher cost and time burden, whereas smaller-scale curricula require more local buy-in and influence. The overall goal is not to create experts, but rather to make health care policy knowledge accessible. Each program was able to recognize local needs and resources to create time-proven models that can be replicated and expanded upon to inform practitioners and create health care policy leaders and educators.21
Interventions can be made at the departmental, institutional, and national levels to increase advocacy awareness and participation in training. These vary in time commitment and financial support, but can be modified to fit every program.
Incorporating advocacy into an education program
The current need for surgeon engagement raises the question of how we can incorporate advocacy within our education programs and personal practices (see Figure 1). Many simple measures can be initiated at a variety of levels. At the departmental level, similar to how wellness activities have been incorporated into residency programs, time may be set aside to teach advocacy to attendings, residents, and medical students. This activity could be as simple as setting aside a grand rounds to have a trainee, speaker, or local representative discuss the national issues facing health care and the current legislation being discussed that could affect surgeons and patients. This approach could easily be expanded to the institutional level by orchestrating a multidisciplinary session to discuss how health care policy affects all fields of medicine. A session on advocacy also could be incorporated into a program’s education curriculum and could be pursued on the national level by incorporating it into the SCORE (Surgical Council on Resident Education) curriculum, which many training programs use. Similarly, time in medical student curricula can be reserved to discuss these topics, as much education is lacking in this arena.
FIGURE 1. OPPORTUNITIES TO MAKE HEALTH CARE ADVOCACY MORE ACCESSIBLE
As previously mentioned, the ACS provides scholarships for residents to attend the annual Advocacy & Leadership Summit, which exposes trainees to the relevant issues affecting surgeons and how to advocate. Similarly, surgery programs can set aside money allocated for advocacy in their budget and provide some financial resources to send residents to the conference or other advocacy programs. Residents who attend the summit can then educate their colleagues on their experiences at the summit and share their thoughts on how they can continue to advocate for surgery at their home program.
Just as residents are required to participate in quality improvement projects, curricula may be developed to promote advocacy. One initiative could be as simple as having an advocacy day during which representatives from the program can visit the state capitol to discuss health care policy and reform. For trainees with time constraints that make traveling difficult, a more viable option is to set aside an hour to organize a letter-writing campaign. The ACS Professional Association established SurgeonsVoice to provide resources to surgeons to become more involved with advocacy.7 The website includes templates of letters to send to representatives to voice support or concern for certain measures.
Health care policy affects our ability to provide care to our patients on multiple levels. Our ability to train the next generation of physicians, the services we are able to provide, and access to those services all are restricted by laws and regulations created by those stakeholders that have been able to secure the most influence rather than physicians and patients. We owe it to ourselves and our patients to become more active participants in this process.
There are various ways to get more involved. Some may choose to devote time to engaging in advocacy, whereas others may decide to support advocacy financially. It is important that surgeons remain active and engaged in these processes for ourselves, our patients, and the surgical community.
- Tyson P. The Oath: Meaningless relic or invaluable moral guide? PBS. 2001. Available at: www.pbs.org/wgbh/nova/article/hippocratic-oath-today/. Accessed March 25, 2021.
- American Board of Surgery. Becoming certified. Available at: www.absurgery.org/default.jsp?examoffered. Accessed April 2, 2021.
- The American Board of Surgery Maintenance of Certification Program: The first 10 years. Bull Am Coll Surg. 2015;100(7):15-19. Available at: https://bulletin.facs.org/2015/07/the-american-board-of-surgery-maintenance-of-certification-program-the-first-10-years/. Accessed July 2, 2021.
- The Joint Commission: Over a century of quality and safety. History timeline. Available at: www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/assetmanager/tjc_history_timeline_through_2015pdf.pdf?db=web&hash=C0535242E1E1BB9F54762C47BCAAF6D4. Accessed July 7, 2021.
- American Board of Surgery. Update on new direction for continuous certification. Available at: www.absurgery.org/default.jsp?news_mocupdate1117. Accessed July 15, 2021.
- State legislative priorities. American College of Surgeons. Available at: www.facs.org/advocacy/state/trends. Accessed April 2, 2021.
- SurgeonsVoice advocacy guide: Tools and resources to become an effective surgeon advocate. American College of Surgeons Professional Association Political Action Committee. Available at: www.facs.org/-/media/files/advocacy/surgeonsvoice/surgeonsvoice_advocacy_guide.ashx. Accessed April 2, 2021.
- Douglas RG, Hayes JG, Roberts RB, Bardes CL. Bell Commission requirements: Doctors or factory workers? Trans Am Clin Climatol Assoc. 1990;101:91-98.
- Baker J, Misra S, Manimala NJ, Kuy S, Gantt G. The role of politics in shaping surgical training. Bull Am Coll Surg. 2013;98(8):17-25. Available at: https://bulletin.facs.org/2013/08/the-role-of-politics/. Accessed July 7, 2021.
- Bilimoria KY, Chung JW, Hedges L V, et al. Development of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial protocol: A national cluster-randomized trial of resident duty hour policies. JAMA Surg. 2016;151(3):273-281.
- Khorfan R, Yuce TK, Love R, et al. Cumulative Effect of flexible duty-hour policies on resident outcomes: Long-term follow-up results from the FIRST Trial. Ann Surg. 2020;271(5):791-798.
- Boyle P. Medical school enrollments grow, but residency slots haven’t kept pace. Association of American Medical Colleges. September 3, 2020. Available at: www.aamc.org/news-insights/medical-school-enrollments-grow-residency-slots-haven-t-kept-pace. Accessed March 29, 2021.
- Heiser S. AAMC Endorses Resident Physician Shortage Reduction Act of 2021. Association of American Medical Colleges. March 18, 2021. Available at: www.aamc.org/news-insights/press-releases/aamc-endorses-resident-physician-shortage-reduction-act-2021. Accessed July 7, 2021.
- Resident Physician Shortage Reduction Act of 2011. Library of Congress. September 23, 2011. Available at: www.congress.gov/bill/112th-congress/senate-bill/1627/text. Accessed July 15th, 2021.
- The complexities of physician supply and demand: Projections from 2018 to 2033. American Association of Medical Colleges. June 2020. Available at: www.aamc.org/system/files/2020-06/stratcomm-aamc-physician-workforce-projections-june-2020.pdf. Accessed March 29, 2021.
- Walker JP. Status of the rural surgical workforce. Surg Clin North Am. 2020;100(5):869-877.
- Medvecz AJ, Vogus TJ, Terhune KP. The cost of not training a surgical resident. J Surg Educ. March 17, 2021 [Epub ahead of print]. Available at: www.sciencedirect.com/science/article/abs/pii/S1931720421000441?via%3Dihub. Accessed July 19, 2021.
- Kahn SA, Davis SA, Banes CT, Dennis BM, May AK, Gunter OD. Impact of advanced practice providers (nurse practitioners and physician assistants) on surgical residents’ critical care experience. J Surg Res. 2015;199(1):7-12.
- Wamsley L. Stanford apologizes after vaccine allocation leaves out nearly all medical residents. National Public Radio. December 18, 2020. Available at: www.npr.org/sections/coronavirus-live-updates/2020/12/18/948176807/stanford-apologizes-after-vaccine-allocation-leaves-out-nearly-all-medical-resid. Accessed March 29, 2021.
- Hiruko A. Unsettled contract negotiations add to strain on UW resident doctors on COVID-19 frontline. KUOW National Public Radio. May 12, 2020. Available at: www.kuow.org/stories/unsettled-negotiations-add-to-strain-felt-by-uw-doctors-on-covid-19-frontlines. Accessed July 7, 2021.
- Greysen SR, Wassermann T, Payne P, Mullan F. Teaching health policy to residents—three-year experience with a multi-specialty curriculum. J Gen Intern Med. 2009;24(12):1322-1326.
- Tapia NM, Milewicz A, Whitney SE, Liang MK, Braxton CC. Identifying and eliminating deficiencies in the general surgery resident core competency curriculum. JAMA Surg. 2014;149(6):514-518.
- American College of Surgeons. Health policy scholarships. Available at: www.facs.org/Member-Services/scholarships/health-policy. Accessed March 20, 2021.
- Jacobsohn V, DeArman M, Moran P, et al. Changing hospital policy from the wards: An introduction to health policy education. Acad Med. 2008;83(4):352-356.
- Robinson TD, Oliveira TM, Timmes TR, et al. Socially responsible surgery: Building recognition and coalition. Frontiers in Surgery. April 5, 2017. Available at: www.frontiersin.org/articles/10.3389/fsurg.2017.00011/full. Accessed July 7, 2021.
- Hufford L, West DC, Paterniti DA, Pan RJ. Community-based advocacy training: Applying asset-based community development in resident education. Acad Med. 2009;84(6):765-770.