the generation gap in modern surgery the royal infirmary manchester u.k. april 1, 2004 terry c....
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The Generation Gap in Modern Surgery
The Royal Infirmary The Royal Infirmary
Manchester U.K.Manchester U.K.
April 1, 2004April 1, 2004
Terry C. Hicks, MDTerry C. Hicks, MDNew Orleans, La.New Orleans, La.
• Surgeons are the Marines of medicine
• A chance to cut is a chance to cure
• When in doubt cut it out
• Don’t let the skin stand between you and the diagnosis
• Suffering builds character
The Atttitude of 1977
Dramatic Changes Occur in the Field of Medicine during the past two decades
Research Research EducationEducation Organization and practice of medicine.Organization and practice of medicine. Increase number of women and minority students entering Increase number of women and minority students entering
medical careers. medical careers. Society and governmental policies exerting pressure on Society and governmental policies exerting pressure on
students to enter primary care medicine. students to enter primary care medicine. The effects of business, insurance, and a legal interest.The effects of business, insurance, and a legal interest. Loss of physician prestige.Loss of physician prestige. Constraints on physician and patient relationships.Constraints on physician and patient relationships. The effects of lawsuits and the internet.The effects of lawsuits and the internet. Students burdensome debts?Students burdensome debts?
The Perception of the Generation Gap in Modern Surgery
Work EthicWork Ethic
CommitmentCommitment
VisionVision
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% Matched by US Seniors% Matched by US Seniors
% Matched by All Students% Matched by All Students
19901990 19911991 19921992 19931993 19941994 19951995 19961996 19971997 19981998 19991999 20002000 20012001
Data extracted from the 1990-2001 National Resident Matching Program results. Data Data extracted from the 1990-2001 National Resident Matching Program results. Data represent the number of represent the number of general surgery positions filled by US senior medical students filled by US senior medical students and all students combined (foreign medical graduates, osteopathic students, and other and all students combined (foreign medical graduates, osteopathic students, and other physicians).physicians).
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% Matched by US Seniors% Matched by US Seniors
% Matched by All Students% Matched by All Students
19901990 19911991 19921992 19931993 19941994 19951995 19961996 19971997 19981998 19991999 20002000 20012001
Data extracted from the 1990-2001 National Resident Matching Program results. Data Data extracted from the 1990-2001 National Resident Matching Program results. Data represent the number of represent the number of positions in anesthesia filled by US senior medical students and all filled by US senior medical students and all students combined (foreign medical graduates, osteopathic students, and other physicians).students combined (foreign medical graduates, osteopathic students, and other physicians).
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% Matched by US Seniors% Matched by US Seniors
% Matched by All Students% Matched by All Students
19901990 19911991 19921992 19931993 19941994 19951995 19961996 19971997 19981998 19991999 20002000 20012001
Data extracted from the 1990-2001 National Resident Matching Program results. Data Data extracted from the 1990-2001 National Resident Matching Program results. Data represent the number of represent the number of positions in diagnostic radiology filled by US senior medical filled by US senior medical students and all students combined (foreign medical graduates, osteopathic students, students and all students combined (foreign medical graduates, osteopathic students, and other physicians).and other physicians).
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%
% Matched by US Seniors% Matched by US Seniors
% Matched by All Students% Matched by All Students
19831983 19841984 19851985 19861986 19871987 19819888
19891989 19901990 19911991 19921992 19931993 19941994
Data extracted from the 1990-2001 National Resident Matching Program results. Data Data extracted from the 1990-2001 National Resident Matching Program results. Data represent the number of represent the number of positions in emergency medicine filled by US senior medical filled by US senior medical students and all students combined (foreign medical graduates, osteopathic students, students and all students combined (foreign medical graduates, osteopathic students, and other physicians).and other physicians).
19951995 19919966
19971997 19981998 19991999 20002000 20012001
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General SurgeryOrthopedicsNeurosurgeryOtolaryngologyUrology
Stu
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’ F
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%
1978 1980 1982 1984 1986 1988 1990 1992 1995 1999 2001
Data extracted from the 1978-2001 Medical Student Graduation Questionnaire All Schools Report, excluding 1993 (unavailable). Data represent US senior students’ first choice of residency ongraduation and are expressed as a percentage of the respondents each year for the listed surgical specialties.
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atc
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urg
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Se
nio
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%
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Data extracted from the 1994-2001 National Resident Matching Program results. Data represent the recent declining trend of medical students’ interest in general surgery expressed as a percentage. The linear projection estimates the number of positions that will be matched or filled by US senior medical students will be in the year 2005 if the trend continues and the number of positions offered remains the same.
Y=--1.156x2394.4 R2=0.67 P=.001
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Medical Students Interested in General Surgery
YOU MAKE THE CALL
The decrease in The decrease in categorical physicians categorical physicians in surgery can be in surgery can be attributed best to :attributed best to :
a. Night call and in-hospital work hours.
b. Lifestyle issues.c. Duration of training.d. Lack of flexibility in
training programs.e. Other.
Influences Mean Score
5 Most Influential Type of patient problems encountered 3.3 Clerkships in the area 3.2 Intellectual content of the specialty 3.2 Challenging diagnostic problems 3.2 Example of physician in the specialty 3.1 Possess special skill/talents unique to the specialty 3.0 Predictable work hours 2.05 Least influential Level of educational debt 0.8 Length of residency 1.3 Lack of overcrowding in the field 1.4 Prestige within the medical profession 1.5 Good income 1.8
Factors Influencing Senior StudentsChoosing a Specialty*
The Antidote of Choice
One of The Fears One of The Fears Associated with Associated with
Choosing General Choosing General Surgery as a Surgery as a
SpecialtySpecialty
One of The Fears One of The Fears Associated with Associated with
Choosing General Choosing General Surgery as a Surgery as a
SpecialtySpecialty
Why the numbers are dropping in General Surgery (cont.)
Few students would be willing or foolish Few students would be willing or foolish enough to endure the sacrifices strictly for enough to endure the sacrifices strictly for monetary gain, especially when there are monetary gain, especially when there are easier ways of achieving financial security easier ways of achieving financial security (business school, law school).(business school, law school).
Is there any validity to the notion that Is there any validity to the notion that students who consider fields other than students who consider fields other than surgery are lazy? surgery are lazy?
Why the numbers are dropping in General Surgery (cont.)
Are we different than the greatest generation of Are we different than the greatest generation of hardworking and helpful people described in hardworking and helpful people described in Tom Brokaw’s book Tom Brokaw’s book The Greatest GenerationThe Greatest Generation? ?
The definition of The definition of lifestylelifestyle for most students for most students today is time. With a finite amount of time in the today is time. With a finite amount of time in the day, more time at work means less time with the day, more time at work means less time with the family or friends. family or friends.
A surgeon looks at specialty selection
Are surgeons born or made?Are surgeons born or made? A trip back to the anatomy dissection table.A trip back to the anatomy dissection table. Follow the psychodynamics at a code being run Follow the psychodynamics at a code being run
in a hospital.in a hospital. Being a quarterback versus finding a comfort Being a quarterback versus finding a comfort
level.level. Is surgery more demanding? Time, technical skill, Is surgery more demanding? Time, technical skill,
and cognitive ability? and cognitive ability? What is the role of the students’ exposure to What is the role of the students’ exposure to
surgical teaching during his medical school surgical teaching during his medical school curriculum? curriculum?
The Modern Medical School Graduate and General Surgical Training –
Are they compatible?
The student (gender and age)The student (gender and age)
There is a 52% drop in total number of men apply to medical school since There is a 52% drop in total number of men apply to medical school since 1974.1974.
Women now comprise nearly 50% of graduating students from medical Women now comprise nearly 50% of graduating students from medical schools.schools.
General Surgery remains a white male-dominated profession with only General Surgery remains a white male-dominated profession with only 10% of practicing surgeons being female. Therefore, General Surgery is 10% of practicing surgeons being female. Therefore, General Surgery is appealing to predominately half the students it use before the gender appealing to predominately half the students it use before the gender shift. shift.
The Modern Medical School Graduate and General Surgical Training –
Are they compatible? (con.t)
There is a wives’ tale that the entering medical student is now There is a wives’ tale that the entering medical student is now older and has given up the idea of surgery because of older and has given up the idea of surgery because of increased age.increased age.
In fact, there has not been a change in the mean age of In fact, there has not been a change in the mean age of medical students in the last 10 years (average for men and medical students in the last 10 years (average for men and women approximately 24 years old on entry into medical women approximately 24 years old on entry into medical school).school).
The Modern Medical School Graduate and General Surgical Training –
Are they compatible? (con.t)
Ethnicity Ethnicity
African Americans, American Indians, and Hispanics graduating from African Americans, American Indians, and Hispanics graduating from medical school has increased from 2,890 in 1974 to approximately 4,181 medical school has increased from 2,890 in 1974 to approximately 4,181 in 1999. in 1999.
Minority groups account for 9.3% of all general surgery training Minority groups account for 9.3% of all general surgery training positions.positions.
There is a lack of minority role models in academic departments of There is a lack of minority role models in academic departments of surgery (may lead to lack of interest by minority students).surgery (may lead to lack of interest by minority students).
Generation X Those born since 1965 are known as Generation X.Those born since 1965 are known as Generation X. This generation is noted to want autonomy, a flexible This generation is noted to want autonomy, a flexible
schedule, and a predictable lifestyle. schedule, and a predictable lifestyle. Generation X works hard at keeping work and lifestyles Generation X works hard at keeping work and lifestyles
separate and balanced.separate and balanced. Traditionally, this approach has been important only for Traditionally, this approach has been important only for
women, but now it is becoming increasingly important to women, but now it is becoming increasingly important to men. men.
Third year surgery clerkship GWU is the highest rated Third year surgery clerkship GWU is the highest rated clinical rotation and the second highest rated course in the clinical rotation and the second highest rated course in the entire curriculum for medical students; yet on average less entire curriculum for medical students; yet on average less than 10% of the graduating class choose general surgery.than 10% of the graduating class choose general surgery.
The majority students cited call schedule, length of training, The majority students cited call schedule, length of training, or poor lifestyle of surgeons is why they chose other fields.or poor lifestyle of surgeons is why they chose other fields.
The Faculty Mentor Because of the paucity of female and minority general Because of the paucity of female and minority general
surgeons, most female and minority students have surgeons, most female and minority students have white male mentors. white male mentors.
Medical students have a poor exposure to the lifestyle Medical students have a poor exposure to the lifestyle of practicing general surgeons.of practicing general surgeons.
Due to cutbacks in academic positions, surgeons are Due to cutbacks in academic positions, surgeons are less involved in first and second year medical less involved in first and second year medical students.students.
Surgical clerkships have been shortened by 30% at Surgical clerkships have been shortened by 30% at some medical schools. some medical schools.
Studies have shown students are attracted to fields in Studies have shown students are attracted to fields in which instructors are energetic and motivated.which instructors are energetic and motivated.
The Faculty Mentor (cont.)
New England Journal of Medicine points out New England Journal of Medicine points out 33% of physicians are either dissatisfied or 33% of physicians are either dissatisfied or very dissatisfied with the current medical very dissatisfied with the current medical practice. practice.
Medical students are not told of the joys of Medical students are not told of the joys of general surgery, yet are told of the general surgery, yet are told of the mandatory trauma, poor reimbursement, mandatory trauma, poor reimbursement, medical legal issues, and management care medical legal issues, and management care pressures.pressures.
Medium debt of medical students graduating from Medium debt of medical students graduating from private and public medical schools has increased 300% private and public medical schools has increased 300% since 1985 ($110,000 and $80,000 respectively in 1999).since 1985 ($110,000 and $80,000 respectively in 1999).
Students have utilization of internet sites such as Students have utilization of internet sites such as www.salary.comwww.salary.com (physician income data). (physician income data).
There is a significant association between medium There is a significant association between medium income of physicians practicing their specialty and the income of physicians practicing their specialty and the competitiveness for U.S. seniors in the match process. competitiveness for U.S. seniors in the match process.
Remember, cardiothorasic surgery has a high-end Remember, cardiothorasic surgery has a high-end salary. This is one of the less competitive fields now salary. This is one of the less competitive fields now due in part to the grueling lifestyle. due in part to the grueling lifestyle.
DEBT
Why the numbers are dropping in General Surgery
The answer no one wants to hear – Lifestyle!The answer no one wants to hear – Lifestyle! The concept that some words can only be The concept that some words can only be
whispered. whispered. In the surgical community, lifestyle has In the surgical community, lifestyle has
become equated with material wealth and become equated with material wealth and sloth.sloth.
Reimbursement may be a factor in some Reimbursement may be a factor in some students’ decision.students’ decision.
The philosophic approach of the modern medical student
Do you live to work or work to live?Do you live to work or work to live?
When I’m lying on my back in the last moments of When I’m lying on my back in the last moments of my life, I doubt very much I will be concerned my life, I doubt very much I will be concerned about the plaques on my wall, or where I fit into about the plaques on my wall, or where I fit into the executive food chain. Genuine satisfaction the executive food chain. Genuine satisfaction comes from a life of giving, supporting, and being comes from a life of giving, supporting, and being a significant person in the life of your children and a significant person in the life of your children and loved ones.loved ones.
The New Resident Duty Hours: Big Changes, Bigger Challenges
Surgical training historically was justified “Character Building” or Surgical training historically was justified “Character Building” or “Right of Passage”“Right of Passage”
Osler describes postgraduate training with tones of crime and Osler describes postgraduate training with tones of crime and punishment.punishment.
Osler describes physicians being literally “Interned” in the hospital Osler describes physicians being literally “Interned” in the hospital for the first year.for the first year.
Your personal experience: Struggling to maintain consciousness Your personal experience: Struggling to maintain consciousness after a long night on call with lack of sleep, falling asleep in after a long night on call with lack of sleep, falling asleep in conference, dozing off at the end of a retractor, nodding off while conference, dozing off at the end of a retractor, nodding off while driving home. driving home.
Then came Libby Zion
In 1984, Libby Zion, an 18 year-old female, presents to the In 1984, Libby Zion, an 18 year-old female, presents to the emergency room with Cornell Medical Center Hospital.emergency room with Cornell Medical Center Hospital.
A few hours after admission, she died!A few hours after admission, she died!
Mr. Zion, Libby’s father, a former federal prosecutor and writer Mr. Zion, Libby’s father, a former federal prosecutor and writer for the New York Times charged her death was due to care given for the New York Times charged her death was due to care given by overworked and under-supervised residents. by overworked and under-supervised residents.
Grand Jury investigation exonerated the hospital and Grand Jury investigation exonerated the hospital and physicians, but shed a light on the whole system of residency physicians, but shed a light on the whole system of residency training and supervision. training and supervision.
Then came Libby Zion (cont.)
In 1989, “The Bell Commission” makes its recommendations to In 1989, “The Bell Commission” makes its recommendations to the state of New York, and the first rules regarding residency the state of New York, and the first rules regarding residency duty hours were passed.duty hours were passed.
Initially, only hospitals were held responsible and not training Initially, only hospitals were held responsible and not training programs when violations were identified. programs when violations were identified.
The rules went into effect in New York in the early 1990s but The rules went into effect in New York in the early 1990s but provided a “surgical exclusion”. provided a “surgical exclusion”.
In 1999, the state of New York began enforcing regulations on In 1999, the state of New York began enforcing regulations on surgery programs as well. surgery programs as well.
Then came Libby Zion (cont.)
In 2001, John Conyers (D-MI) introduces House In 2001, John Conyers (D-MI) introduces House Regulation 3236.Regulation 3236.
In the face of these pressures, the ACGME decided In the face of these pressures, the ACGME decided to propose consistent work rules for all residency to propose consistent work rules for all residency programs. programs.
ACGME Rules
80 hour work week averaged over four weeks. 80 hour work week averaged over four weeks. 24 hour on duty limit (with six hour extension for 24 hour on duty limit (with six hour extension for
“patient continuity” and education).“patient continuity” and education). One 24 hour period per week free from clinical One 24 hour period per week free from clinical
duties. duties. In-house call no more than every third night.In-house call no more than every third night. 10 hour rest period between all clinical duty 10 hour rest period between all clinical duty
periods.periods.
Programs and Institutions Cited for Noncompliance With Work Hours and Related Requirements*
Program Cited, %Program Cited, %
Specialty 1999 2000
Anesthesiology 2 2Emergency medicine 10 6Internal medicine 30 10Pediatrics 21 16Psychiatry 0 0
Surgery Colorectal 33 6 Neurological 10 5 Orthopedic 29 10 General 36 35 Vascular 17 9 Pediatric 53 44 Urology 8 3
*Data from Leach.
More Creative Ideas to Comply with ACGME Requirements
Redefine resident and staff duties to free Redefine resident and staff duties to free residents up from non-educational “scut” residents up from non-educational “scut” work. work.
The hiring by hospitals of mid-level The hiring by hospitals of mid-level providers (physician assistants, nurse providers (physician assistants, nurse practitioners, and surgical assistants). practitioners, and surgical assistants).
Do House Officers Learn From Their Mistakes?
This study published in The New England Journal This study published in The New England Journal of Medicine reported that 41% of 145 residents of Medicine reported that 41% of 145 residents surveyed cited fatigue as a cause of their most surveyed cited fatigue as a cause of their most serious mistake. In nearly 1/3 of the cases, the serious mistake. In nearly 1/3 of the cases, the patient died as a result of the error!! patient died as a result of the error!!
…there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success than to take the lead in the introduction of a
new order of things. Because the innovator has the following
enemies: all those who have done well under the old
conditions, and lukewarm defenders who may do well
under the new conditions. NICOLO MACHIAVELLI NICOLO MACHIAVELLI
The PRINCE The PRINCE
A Historical View of Paradigm ShiftsA Historical View of Paradigm Shifts
The New Paradigm
Traditional Philosophy – Selection of specialty Traditional Philosophy – Selection of specialty based on specialty content, prestige, and financial based on specialty content, prestige, and financial remuneration.remuneration.
The New Paradigm – Considerations of the length The New Paradigm – Considerations of the length of training, number of hours on call, likelihood of of training, number of hours on call, likelihood of litigation, and expected control of their litigation, and expected control of their occupational work hours.occupational work hours.
