Surgical Education Week

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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
Dick Kieffer
George Zuidema
Tom Gadacz
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The Vanderbilt Yearsthe 1990s
John Sawyers
Walter Merrill
Wright Pinson
Jim ONeill, Jr.
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The Vanderbilt Years-2000s
Jeff Dattilo
Naji Abumrad
Dan Beauchamp
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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 Week
• Wednesday
• 16 April 2008
• Toronto

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Past APDS Presidential Addresses

• 2007Jim Valentine
• The Neglected Specialty
• 2006Joe Cofer
• This Is Not your Mothers APDS
• 2005John Potts
• Dawnof a New Day in Surgical
  Education
• 2004Richard Welling
• The Evolving Renaissance in Surgery
  Education
• 2003Tom 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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PD ACGME RRC/ABS
Resident as Ping Pong Ball
Attendings Chiefs
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Q What is the biggest problem, challenge in your
program?AAMC Chief Medical Officer-Group on
Faculty Practice3 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
Unequal Treatment Confronting Racial and Ethnic
Disparities in Health Care--2002

• National
• Global

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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 womens health
  issues
• Analgesiaperi-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 affectedby 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 88877-882, 1927
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To heal a person,one must first be a person.
Abraham Joshua HeschelThe Patient as a
PersonThe Insecurity of Freedom. Farrar,
Strauss Giroux. 1966.
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Three Points

• I. General Surgery
• II. Surgical Formation
• 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 143345-350, 2008.

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Income Medicare 30-Year Impact
Rothman, 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 ones (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 Coffin
• A Passion for the Possible
• Westminster/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 FormationIntentional and Reflective

• Industrial Model Formation Model
• Show up on time Ongoing, continuous
  acquiring
• Pay attention Journey, not a destination
• Hierarchy Team sport
• Teacher gt Student Co-learners
• Fixed Period Lifetime process
• Cantaloupe Grape Process, not an event

Aschenbrener
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Education is not filling pailsit is lighting
fires. William Butler Yeats1865-1939, Irish
Poet and Dramatist1923 Nobel Prize for
Literature (Poetry)
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O
Burns
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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
• ACGME Resident
• Work Restrictions
• 1960s Womens Liberation

Abraham Flexner
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1964
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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 BlackVanderbilts 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 ShepherdPD, Henry Ford
• Jim SitzmanFormer Chair at Georgetown and
  Rochester, now at Indiana U
• Linda ReillyFirst 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,
19652006. 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
3571889-1891,2007
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Women in General Surgery Residency
30 to 25
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Challenges confronting female surgical leaders
overcoming the barriers.

• Perseverance
• Drive
• Good Communication Skills
• A Passion for Scholarship
• A Stable Home Life
• A Positive Outlook
• Souba, WW.
• J Surg Res 132179-187, 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 236263-269, 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 marriages
• MR Lewin, Ann Emer Med 41568-573, 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 1981
• 5.69 per 100K 2005
• Women disproportionately concentrated in urban
  areas
• Lynge et al. Arch Surg 143345-350, 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 96846-855, 2006.

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Preeclampsia Sucks.

• A threat to the mother gt the child.
• 18of 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

• gt Parenting during training
• gt Child care
• gt Parental leave
• gt On-site child care
• R Jagsi, NJ Tarbell, DF Weinstein.
• N Engl J Med 3571889-1891, 2007.
• (SMNC ClubBill 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 236263-269, 2002
• American 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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(No Transcript)
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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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S 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 82113-120, 1999.

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24/7 Child Care for Our Residents
and Faculty, etc

• Toyota can do it since 1993(http//www.pbs.org/
  wnet/moneyshow/cover/011201.html ).
• Why not the American Surgical Community?

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,
• lets rejoice, encourage, and facilitate our
  residents being the complete individuals our
  patients and society deserves.
• Lets create systems to support our surgical
  progeny.
• Lets 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