surgical education week 15 april 2008 toronto. “people need to be reminded more often than they...
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Surgical Education Week
15 April 2008
Toronto
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“People need to be reminded more often than they need to be instructed.”
Dr. Johnson
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The Hopkins Years
George Zuidema
Dick Kieffer
Tom Gadacz
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The Vanderbilt Years—the 1990s
John Sawyers
Walter Merrill
Wright Pinson
Jim O’Neill, Jr.
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The Vanderbilt Years-2000s
Jeff DattiloDan Beauchamp Naji Abumrad
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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.
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“What Business Are We In?”
Surgical Education WeekWednesday
16 April 2008Toronto
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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
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“The primary purpose of residency is the education of the resident, not service to the hospital.”
Frank Spencer, NYU. 1992.
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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
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Resident as Ping Pong Ball
PDACGME
RRC/ABS
Attendings
& Chiefs
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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.
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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
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IOM: Disparities of Care
National
Global
Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care--2002
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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
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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
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“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
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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.
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Three Points
I. General Surgery
II. Surgical Formation
III. Sociology and Surgery
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General Surgery and Its Iterations
Important, Meaningful
Workforce Projections = Job Security
Remuneration
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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.
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Income: Medicare 30-Year ImpactYear Average Physician
Income
1966 $28,000
1970 $41,800
1975 $56,400
1982 $100,000
1997 $199,600Rothman, 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)
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II. Surgical Formation
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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.
Spiritual Formation
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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 CoffinA Passion for the PossibleWestminster/John Knox Press.
1993.
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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.
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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
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Surgical Formation:Intentional and Reflective
Industrial Model Formation ModelShow up on time Ongoing, continuous
acquiring
Pay attention Journey, not a destination
Hierarchy Team sport
Teacher > Student Co-learners
Fixed Period Lifetime process
Cantaloupe: Grape Process, not an event
Aschenbrener
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“Education is not filling pails;it is lighting fires.”
William Butler Yeats
1865-1939, Irish Poet and Dramatist1923 Nobel Prize for Literature (Poetry)
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OBurns
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Head: Cognitive, Judgement
Hands: Technical
Heart: People Skills, Respect
Health: Lifestyle
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III. Sociology and Surgery
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100 Years of Surgical Education
1910 Flexner Report
1964 Medicare
2003 ACGME Resident
Work Restrictions
1960s Women’s Liberation
Abraham Flexner
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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
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Surgery, Hopkins, July 1970
Pyramid
No SICU
No CT
No Laparoscopy or MIS
No Women
One Black
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Baltimore, July, 1970
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Hopkins Surgery 1977
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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
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Linda Reilly, MD
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Baptist Medical Centre
Ogbomoso, Nigeria 1978-1993
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Nigerian Surgeons
JK Ladipo
Akin OlaOlorun
Wole Adebo
Layi Adeoti
M T Shokunbi
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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
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Women in General Surgery Residency
30 to 25%
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“Challenges confronting female surgical leaders: overcoming the barriers.”
PerseveranceDriveGood Communication SkillsA Passion for ScholarshipA Stable Home LifeA Positive Outlook
Souba, WW. J Surg Res 132:179-187, 2006
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Lauren Nicolle
Lauren, Rebecca, Jay
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Kilyn and Conner
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Miller, Kai, Keller
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Christopher, Nia, Tia
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Chief Class of 2005
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About Two Weeks Ago
Tuesday, 1 April 2008
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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
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Pregnancy, Parenthood and Family Leave during Residency
90% male MDs marry
70% female MDs marry
90% marry professional men
50% dual-MD marriagesMR Lewin, Ann Emer Med: 41:568-573, 2003
(But 100% are members of a family.)
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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 19815.69 per 100K 2005
Women disproportionately concentrated in urban areas
Lynge et al. Arch Surg 143:345-350, 2008.
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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.
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“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
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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)
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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, 2002American Surgical Association Presidential Address
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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.
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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!
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Doris Risley
Vanderbilt Coordinator 1993-2005
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Stephanie Rowe Alli Watts
The Vanderbilt Surgical Education Team
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Deborah Greene and Remona Weakley of the Nashville VAMC
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"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.
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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.
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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.
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24/7 Child Care for Our Residents
Toyota can do it – since 1993(http://www.pbs.org/wnet/moneyshow/cover/011201.html ).
Why not the American Surgical Community?
and Faculty, etc
IRB: “Assessing the Need by Residents, Resident Spouses, and Medical Students of Additional Institution-Based Child Care Services” Kyla Terhune, PI, Vanderbilt
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Rick Keuler, Kyla Terhune, & Tate
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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.
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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