What is Right and What is Wrong with Our Process of Educating Doctors?

 

 

By “doctors” I refer to practitioners of the medical profession.  The term “doctor” comes from the Latin word docere which means to teach.  It dates back to the middle ages when universities awarded the academic title of doctor to individuals that fulfilled certain requirements of study that gave them the license to teach at universities.  The first such title was awarded at the University of Bologna in Italy.  Traditionally it was awarded to individuals that earned the right to teach divinity, law, and medicine.  Later it branched out to other subjects, philosophy, pharmacy, musicology, etc.  Now the title is used appropriately for anyone who has earned the proscribed number of courses and has passed rigorous exams in their field.  For medicine it would be the M.D. degree, for law- J.D., for many others PH.D serves that purpose.

My dissertation is limited to medical doctors, and more specifically to surgeons.  In my era, which covers the last half century from 1967, when I earned my M.D. degree, to the present there has been a tremendous explosion of knowledge in everything, including the field of surgery.  I feel particularly qualified to hold an opinion on the education of a doctor, as I have grown up in this era of rapid evolution of various diagnostic and therapeutic interventions, such as the CT scanner, originally called the EMI scanner (Electric and Music Industries- a company funded by the enormous financial success of, none other than the Beatles).  I have, of course, been on both sides of the equation, as a student and as a teacher.  I started teaching doctors after Vietnam when I returned from the Air Force to practice General Medicine.  Family Practice was just finding its niche and I was on the teaching faculty of an institution that taught that specialty.  I interrupted that activity when I decided to acquire more of my own knowledge in surgery by returning to a residency that gave me the skills and knowledge to be a surgeon. I resumed my role as a teacher in 1981 when I finished that training program and became a board-certified surgeon.  The last 5 years of my half century career has been spent as Program Director of a Surgical Residency.  As I ponder my experiences on the sun set of my career as a doctor, a surgeon, and a teacher, I have come to some conclusions that I would like to share.

War, despite its horrors, has been particularly helpful in figuring out how to help human beings that are injured, especially victims of the brutality of humans against other humans, by whatever malevolent means they can:  slings and arrows of outrageous fortunes, knives, blunt blows, starvation, poisonous substances, radiation, bullets, explosions, sound frequencies, and others some of which are still to be discovered.  World War I, the war that was supposed to end all wars (but didn’t), taught us much about the penetrating abdominal injury and the need for exploratory laparotomy.  Every soldier that got a gun shot wound in the abdomen and injured the large bowel had a 60% chance of dying, if he survived the initial wound.  In the 1940’s Sir William Oglivie reduced the mortality to 30% by simply mandating that all colon injuries should have a diverting colostomy.  World War II also introduced the need for blood banks, and the wonder drug, Penicillin, which was an accidental discovery by Alexander Fleming, when he noticed a strange fungus contaminating his bacterial cultures, which killed the bacteria that he was trying to study.  Korea added more knowledge about vascular surgery by utilizing the research of Dr. Michael DeBakey in repairing injured arteries, and reviving the principle learned by Napoleon’s Surgeon General, Baron Larrey, who realized that the sooner a surgeon sees the injured soldier after his injury, the better chance of his survival.

The MASH (Mobile Army Surgical Hospital) achieved that.  Vietnam gave us an understanding of Da Nang lung, later called ARDS, when the lungs fill up with fluid because the capillaries leak.  Another menace was the triangle de mort, acidosis, hypothermia, and coagulopathy.  If the patent exhibited those harbingers of death, the surgery had to be stopped immediately, and only “damage control” measures performed: stop bleeding by whatever means, stop contamination by the fastest means possible, even if it meant just stapling across damaged intestines without reconstituting continuity, and getting out.  Come back the next day, after the patient has been resuscitated, warmed, blood pressure, and blood volume restored, electrolytes and acidosis corrected.  As an old dictum says, “He who fights and runs away, lives to fight another day.”   That was further developed during the Middle Eastern conflicts, Desert Storm and Afghanistan.  The long-maligned tourniquet, that was thought to do more harm than good, made a comeback to stop exsanguination from an extremity if used appropriately.

Doctors used to be much more versatile, from pulling teeth, to drilling holes in the skull, releasing pressure created by a bleeding artery inside the bony compartment, so that the soft brain would not be squeezed out of the only exit hole, like toothpaste, and kill the patient.  Any good doctor could cut off a leg in less than a minute during the Civil War, or more recently, treat a tonsillar abscess or a heart attack or deliver a baby.

I know this philosophy quite well.  As a medical student, every service that I came on instantly became the one thing I wanted to do.  When I was on the Orthopedic Service, I knew that fixing bones was my favorite thing to do until I was on Obstetrics when nothing was more rewarding than bringing a new life into this world.  On Urology figuring out why that individual suffered from kidney stones, and how to treat this most painful of human scourges, was a decision tree that could not be more challenging. When it came time for me to choose what I wanted to do when I grew up, I could not decide and wound up becoming a general practitioner. Everything was so appealing, and I could do it all!  I did not have to give up setting bones, taking out an infected appendix, or treating a heart attack.  With my residency in General Practice and the military, and then the practice of everything, I spent ten years quite happily.  My favorite though, was using a knife to cure.  With the rapid evolution of medical and surgical knowledge it become obvious to me that doctors became more and more differentiated and skilled in fewer and fewer compartments.  I came to realize that if I wanted to fly airplanes I would have to get a pilot’s license, and if I wanted to cure with a knife, I would have to get my surgeon’s license.  So, I did. That particular endeavor required five years of training at the time.  I asked my wife’s permission to launch this new career for me, and she was initially enthusiastic until she realized what it meant.  I was taking night call every other night, 24 hours on and 12 hours off.  With our first (and as it turned out only child) I was pretty much an absentee father.  I was no help when I came home mostly to sleep.  Within six weeks she said to me, “What have you done to our lives?”  I soon agreed with her and went to the Program Director of my residency to turn in my resignation.  I told him that I thought I was tough, but I was not, I told him that everything has a time and a place and that a 35-year-old married man with a new child had no business starting a new career that was all demanding and all consuming.  He was a wise and understanding man, but he would not let me get out of my contract just yet.  “Come back in three months,” he said, “and we will talk some more.”  I never did, and finished my required time to become a full-fledged surgeon.  I am surprised and grateful that my wife stuck it out with me.

In the 41 years that I have practiced the art and science of surgery, the field has evolved.  The training of surgeons has taken on new procedures, new approaches, new everything!  I do almost nothing the way I was taught.  I learned the new ways mostly by myself, reading, going to weekend courses, spending time with colleagues that could show me the new approach, or going to a center where I could watch the current expert as to how he/she did it.

Surgical education too has changed.  I came from the era of see one, do one, teach one.  That era has gone forever.   Now residents are supervised to a level that is overbearing, but necessary for legal, ethical, and practical reasons.  The idea is to teach the learner in incremental steps, one step at a time.  The learner does not get to advance to the next step until he has mastered the preceding step.  The learner gradually assumes more and more responsibility.  This means he/she never is completely independent until they graduate!  On June 30 of their fifth year they must still answer to their attending supervisor, and on July 1 they are independent surgeons! Also, the time allowed for a surgeon to become competent has been shortened by the 80-hour rule.  A resident may not work more than 80 hours a week on average.  Violating this rule actually could shut down a training program.  So, the rule is adhered to quite compulsively by the program.  To try to circumvent the rule is foolish, as the most common way residency programs get caught is by being turned in by a disgruntled resident, which is not all that uncommon.   I must agree that the tired doctor, or for that matter street cleaner, does a better job when well rested, rather than dead tired, but there needs to be exceptions and less strict interpretation under special circumstances, which in fact has happened to some degree, but still needs tweaking.  Disease processes and surgical care does not respect timetables, schedules, nor any kind of orderly progression.  When things go wrong, multiple things go wrong, often all at once.  The best surgeon to have input in a crisis is the one who was most intimately involved with the surgery, even a dead tired one.  He or she knows details that were not recorded in any operative notes or post-op progress reports.  Diseases and surgical procedures do not follow the 80-hour rule.  Most of the time this does not happen, or it can be reconciled with the rules, but sometimes it just can’t be.  It is those times that in the interest of the patient’s wellbeing, and the trainee’s educational experience, that rules do not work.  In my training program I would spend at least 100 a week and sometimes 120 hours.  At least 20% more time than happens now.   This has brought the serious consideration for adding yet another year to the already long time of five years required to produce a surgeon.   Eighty percent of graduating residents already add on a year or two themselves as they do not feel competent to go out on their own, by taking a fellowship in some specialty field such as vascular surgery, thoracic surgery, minimally invasive surgery, foregut surgery, colo-rectal surgery, etc.  Although that adds the needed time to mature the surgeon, it reduces the number of general surgeons that are created.

The idea that a general practitioner can do surgery is very much not in concert with modern thinking or practice, except for a few isolated pockets in the country where time has stood still. To spend time and resources to teach primary physicians to perform surgical operations is no longer appropriate in modern times.  Most of them will not put their skills to use unless they practice in the third world.  And teaching primary doctors such skills takes away the opportunity to teach someone who will use those skills.  This is especially inappropriate in institutions that are tax supported, as their focus must be directed to what the needs of our populations are, rather than what Africa’s needs are.  The field of surgery has become so complicated that even the fully trained 5-year surgeon cannot possibly do all the things that are part of his curriculum.  It may be time for us to rethink the goals of training programs.  The idea that all surgeons (or all doctors) should be “Renaissance Men or Women” is not compatible with reality.  There is just too much knowledge; one person cannot possibly acquire or keep up with all of it, given the rapidity with which things change.   Already the general practice doctor across the nation does not care for complex problems, in fact, in most urban areas the general practice doctor does not even enter the hospital to see his patients, except as a visitor.  The patient is cared for by hospitalists and specialty doctors and sees his primary doctor once he or she is discharged from the hospital.  Granted, there are still isolated parts of the country where hospitals have generalists, but any complications or complex issues are quickly transferred to hospitals that deal with complicated problems all the time.    It is not feasible to train a generalist in the depth and breadth that is required to care for complex critical care, in the three years that are allotted to their training.  The same is true for general surgeons, even after the five years required for them.  They too need an additional year of training in critical care to be effective practitioners in a critical care unit.

The agencies that provide oversight to residency training are obsessed that all residents become involved with research, and they mandate that every resident does research.  That is, I believe, over-emphasized.  Again, it seems to me to be an effort to make all doctors all things to all people. I know that I will be branded an iconoclast to criticize the holy grail of research, but in my defense, I am not a research curmudgeon.  Research has, in part, brought us to where we are today, along with bright individuals who stumbled on revelations by serendipity, and recognized their significance. Indeed, we need research to advance our field, but not all doctors are cut out to be scientists, just like not everyone can be an athlete, a surgeon, or an artist.  In fact, most of us are mechanics who are good at doing what the scientists and engineers tell us to do.  Even mechanics have come up with innovative ideas from time to time that have changed the world—just think of the two bicycle mechanics, Orville and Wilbur Wright.   Although I believe research is necessary, much of it should be done by institutions and individuals that have the means, interest, inclination, and talent to produce worthwhile and meaningful output.  Not all programs have the means to produce meaningful data, especially smaller institutions that deal with making competent surgeons that will be able to handle the common bread and butter surgical problems.  Residents waste too much of time with research that takes effort but does not produce material that has much value. Nor does it add to the resident’s ability to pass exams or become a good surgeon.  Additionally, Program Directors of fellowships use the number of publications a resident has done as a measure of the resident’s worth to their program.  Something that I think is primarily self-serving to the program director. There are very few real scholar surgeons, and they came to that status by possessing remarkable talents that do not reside in all surgeons.  They are well known, but a large percentage of current published material, even peer reviewed, is busy boredom, and is spinning fool’s gold.  It is also expensive and has become a shameless money-making business for a subset of academic physicians in the ivory towers, that borders on extortion, by holding programs ransom, forcing publications that must have Pub. Med. citation numbers from journals they control.  They pass judgement on what gets published and what does not for a rather large fee.  Getting an article published can cost several thousand dollars by the time all costs, including publishing costs, are added in.  Residents that wish to pursue an academic career should apply to academic institutions where research can be an additional field of interest with time set aside for that pursuit. Research should not interfere with the nuts and bolts of the actual surgical education which takes up all the five years with no time to spare, as the time is already woefully impinged by work hour restrictions, and various educational mandates that do not impact the improvement of surgical skill set or knowledge of the learner, such as lectures on a variety of non-surgical topics.  This robs the learner of valuable time that should be used to acquire knowledge and skills that make the resident a better surgeon.  On the other hand, if a resident, or any surgeon has a bright idea or a fascinating patient whose illness can teach all of us, that resident should definitely publish.  But much of the mandated literature is littered with repetitive, borderline material that adds little to the body of knowledge, precisely because it is artificially promoted by the “publish or perish” doctrine.  It is as much a waste of time and money to produce this material as it is to read it.  Meaningful research should be encouraged but not mandated as it now is.  Good teachers are too often discarded because they don’t publish.  Research is said to teach residents to become better critical thinkers.  That may be true but I am equally concerned that the individual who does research is often corrupted by confirmation bias to defend his/her theory rather than learn critical thinking.  My criticism is not so much centered on the research itself, but on the pressure and mandate to do so.

Surgery is a field that is a mixture of a calling, a trade, a profession, a learned skill that requires a special talent, and a vast knowledge base that is exponentially expanding, requiring a desire for life-long learning.  An old Proverb says, “A good surgeon must have an eagle’s eye, a lion’s heart, and a lady’s hand.”  Stated more pragmatically, the person who wishes to become a surgeon has to have a good dose of humanity, tolerance, and gentleness, but nevertheless be willing and courageous enough to wield the sword when necessary.   There are six areas of competency that the surgeon must master in his/her five years of training.

  1. Knowledge of the human body’s inner workings, anatomically, physiologically, and at the molecular level.
  2. Patient care means caring for the patient in a compassionate, competent, and effective manner. For the surgeon it includes the dexterity and anatomic knowledge to safely negotiate the dark inner recesses of the human being.
  3. Life long learning skills and the striving to constantly be better. Also, to look back on the successes and failures of one’s body of work.
  4. Practice the profession in concert with the entire system of medical care available to us. We are no longer the lone wolf, but a wheel of a larger machine designed to treat disease, ease suffering, and bring solace to the body and soul.
  5. Interpersonal and communication skills must be part of the surgeon’s armamentarium, as it helps little if the surgeon cannot convey the plan of action to the team and the patient.
  6. Above all the surgeon must be ethical and professional.

Finally, I am heartened that primarily the American Board of Surgery, but to a lesser extent through cross pollination, the American College of Surgeons, and the Accreditation Council for Graduate Medical Education have finally come to their senses, by eliminating punishing recertification requirements, and have instead implemented a philosophy and a reasonable system that will foster continuing learning rather than keep surgeons from maintaining their certification.