A GIST day - Joy

Hello everyone, Well today was interesting. The challenge of the day was to operate on a patient who had presented with a significant gastrointestinal bleed. The GI service had confirmed the bleeding site as an ulcerated GIST tumor of the duodenum. We had the patient prepared for a pancreaticoduodenectomy if necessary. However, after exploration and performing a Kocher maneuver, we were able to identify the tumor in the 2nd portion of the duodenum and outline clear margins. We then performed a segmental resection with a transverse closure and only minimal luminal reduction. The operation went well and the patient had no intr-operative or immediate post-operative problems. Now to await the pathology and the mitotic count. What a Joy to be able to do such a useful operation for the patient. JTE.

The Joy of a new student rotation

Well this was my first call with the new 3rd year students who started their clerkship this week. One of the students scrubbed in and got to help with deridement of necrotic tissue from a man who had been in an ATV accident and was pinned under the machine while the wheels kept spinning. JTE.

Article about Joyce collection in Buffalo

Buffalo has key role in film about James Joyce
Annie Deck-Miller
Business First
How many people know that Buffalo is home to the world's largest collection of manuscripts and personal effects by perhaps the most influential author ever?
Not nearly enough, believes Buffalo lawyer Patrick Martin.
That conviction underlies Martin's role as co-producer and co-director of the documentary film "Following James Joyce ... Dublin to Buffalo."
In the Buffalo area, says Martin, a partner in Kennedy Stoeckl & Martin PC, "We have a lot of very major assets that, in terms of the cultural life of the city, we've inherited from a very active, savvy group of forbears (and) that have just spent a few decades in the attic, essentially."
The film brings some of those treasures out of the the Poetry Collection at the University at Buffalo's Undergraduate Library, exposing them to a global audience.
The film traces the Irish-born author's travels from Dublin to Paris and to Pola, Croatia; Trieste, Italy; and Zurich, Switzerland -- all cities where he made his home at some point. It charts also the fate of two collections of Joyce's manuscripts, notebooks, private library, correspondence and family portraits -- one rescued from wartime Paris, a second procured from Joyce's friend and publisher, Sylvia Beach -- as they made their way to an unlikely final destination: Buffalo.
The back story
Martin's involvement in the documentary is rooted in his earlier efforts to publish and promote the Mark Twain novelette "A Murder, a Mystery and a Marriage."
A group of European Joyce enthusiasts who were aware of Martin's work on the Twain project asked for his input on ways to commemorate the June 16, 2004, centenary of Bloomsday, the fictional date on which the events of Joyce's masterpiece novel "Ulysses" take place.
"The first thing I thought was, 'OK, well, Buffalo should be part of this,' " Martin says.
He contacted Joyce scholars Stacey Herbert and Luca Crispi, a couple who'd moved from Buffalo to Dublin in 2003 to help create a "Ulysses" exhibit for the National Library of Ireland.
The three of them quickly conceived ways to appeal simultaneously to hard-core Joyce scholars and casual readers, and compiled a list of possible contributors to the project. Largely in order to avoid copyright concerns, they opted for a documentary film format over a printed work.
"Nobody had to tell us that you want to present this thing in a way that is focusing on James Joyce and the integrity of the story, not on Buffalo," he notes.
The next step was to secure funding for the project. Martin first approached Catherine Schweitzer, executive director of The Baird Foundation, who agreed to support the film financially.
With added contributions from the Constance Stafford Charitable Trust, Cameron Baird Foundation, Zemsky Family Foundation, James Joyce Foundation, the Brioni Co. in Italy and the government of Croatia, the filmmakers had a $90,000 budget.
Getting it together
From conception to completion, the 55-minute film was created in less than a year. Filming began in Europe in February and wrapped up in Dublin and Buffalo in March, with cinematographer Marc Degenaar behind the camera.
Herbert and Martin wrote the film's script with input from Crispi and from Buffalo State College English professor Laurence Shine, who provides the documentary's narration.
The team edited the film from three continents, using the Internet as common ground. Martin would begin work at 4:30 a.m. EST, where it was 9:30 a.m. in both Dublin and Capetown, South Africa, where Degenaar is based.
"Following James Joyce" presents commentary from more than 20 people, most of them Joyce scholars and historians. The Buffalo segments of the film include footage of Frank Lloyd Wright's Darwin Martin House and Graycliff Estate, the Albright-Knox Art Gallery and Kleinhans Music Hall and an interview with UB President John Simpson in the room where the Joyce materials are on display.
The film premiered in Buffalo and Dublin in June, coinciding with the Bloomsday centenary, and has since traveled to Trieste. It will be shown in Croatia and Paris in August, and it's a centerpiece of exhibitions by both the Trieste Joyce School and the National Library of Ireland in Dublin.
"The film has been really well-received in Europe. It's gotten more attention in Europe than it's gotten here," says Martin, who estimates that more than 75,000 people will see the film in Dublin alone this summer.
"There's an enormous amount of interest in Europe about our Joyce archive," Martin says. "So all you have to do is provide the means for somebody to recognize these things in an enjoyable way and then the means to make use of it."
There's a chance that that opportunity will come in the not-too-distant future. UB has contacted the International James Joyce Foundation in hopes of attracting the North American James Joyce Conference here in 2007, says Poetry Collection curator Michael Basinski.
If that happens, it will be an opportunity to "rebrand" Buffalo as a locus with considerable cultural allure, says Susan Scholterer, director of cultural tourism for the Buffalo Niagara Convention & Visitors Bureau.
"It's another activity that positions the Western New York region as very rich in culture and history," Scholterer says. While the convention might not draw a significant number of people here -- perhaps 200 scholars -- she believes it might change widely held misconceptions about Western New York.

News and Wishes

Sometimes when the news is not so good we are filled with wishes of things we would like to do. This past week I received a couple of news items that generated some wishes.
First, a dear friend informed me that her husband has prostate cancer. He is getting good treatment. I wished I could tell her everything would be fine, but I know it is highly variable as to outcome.
Second, one of the 4th tear student got a rejection letter from one of the programs to which she is applying. Certainly, no one can predict the outcome of the residency match. JTE.

Side - Effects

Physicians are careful to warn patients of side effects that medications may cause. One of the side effects of being a trauma surgeon is called court time. I just finished talking to an assistant district attorney about an upcoming trial regarding a patient I treated who had been shot. There is very little activity that is less predictable than jury trials. Even though you may only have to testify for 5 or 10 minutes, you still wind up having to block out days on the calendar just to be available. So I will be trying to reschedule things for the next several weeks. First rule = try to move everything up as much as possble. Till next time. JTE.

The Joy of Hernia Surgery

Well today was one of those great teaching days in the OR. I had two inguinal hernia repairs booked. The first turned out to be a very difficult and large direct hernia. I showed the resident I was teaching how to use the Prolene hernia system and described and demonstrated the myopectinate orifice concept. Next we moved on to another interesting case. The next one turned out to be a slider with a portion of the hernia sac incorporating the colon. Lots of good teaching for this one. One the second case also had a student present who really enjoyed the case and the demonstration of the anatomy. All my best. JTE

Return of the Jedi Master

Well colleagues I am back after my enforced technological absence. A major hard drive crash. I am now familiar with Disk wipe and the security requirements of the Defense Department. Anyway, there is so much to make up foor that I do not know where to begin. Just stay tuned for the forthcoming musings. JTE.

On call saga

Well readers here is the saga from my most recent all night stand:
a - pedestrian versus car
b - multiple stab wounds including zone 1 neck exploration
c - single driver roll over
d- fall with cervical fracture
e- lower GI bleed
f- incarcerated incisional hernia
g - head - on with dislocated elbow
h- unbelted passenger, pneumothorax
i - GSW to chest.
Spent most of the time in the OR and ER.
Lots of unit patients now.
Good experience for the residents.
All my best from the JediMaster

Music & Surgery

A little melody with surgery
Music helps relax doctors and can be good for patients

By Peggy O'Farrell
Enquirer staff writer


WORDS AND MUSIC
"Every now and then someone will say, 'Anything but Buffett when they walk in my room. And I say, 'That's what we play on Tuesday,' which is not a day when I operate."Dr. Dan Reilly, hand and shoulder surgeon, Hand Surgery Specialists Inc., and Good Samaritan Hospital "I always ask teenagers or kids who are going to be awake if they want to bring in music. And if I'm not operating on their head or neck, they'll put on headphones and listen to music I probably wouldn't want to listen to."Dr. John Kitzmiller, plastic surgeon, University of Cincinnati, and a fan of jazz and classical music "My collection is very eclectic, but with a strong preference toward things you can sing along with, myself included. One of my nurses will say, 'Who sings this song?' And I'll say, 'Billy Joel,' and he'll say, 'Keep it that way.'"Dr. Charles Mehlman, pediatric orthopedic surgeon, Cincinnati Children's Hospital Medical Center "When the (music) study was published, I got a lot of responses from younger surgeons who wanted to tell me their favorite songs. The funniest I remember is a song by Don McLean, 'Everybody Loves Me Baby, So What's the Matter With You?' "Dr. Karen Allen, psychologist and researcher, State University of New York-Buffalo "Anesthesiologists seem to like blues and jazz a little more. I think they're just a little bit mellower than the rest of us."Dr. Mark Thomas, transplant surgeon, the Health Alliance "Hopefully (Luther Vandross and Barry White) have helped other people get pregnant without our help, so we're trying to use them to our patients' advantage."Dr. Michael Thomas, fertility specialist, Reproductive Health Center
ADVERTISEMENT
Dr. Jennifer Butterfield can't cure "Boogie Fever." But the Kenwood plastic surgeon will operate to it.
While most patients are asleep and don't hear it, music is just as much a part of the operating room environment as beeping monitors and surgeons barking orders for instruments.
Surgeons say music - classical, country, rock, even disco - helps them concentrate. That's important for people who are working with scalpels, lasers and vital organs.
"There are a lot of OR sounds that have no meaning for the operating surgeon," says Butterfield, who's partial to old-school R&B. "It's almost like really loud white noise. Music takes away from the background noise that's too distracting."
Research shows patients benefit
There's plenty of research that says music is good for patients: It relieves stress, eases the perception of pain, even triggers memory in people with Alzheimer's.
Some studies show music is good for surgeons - ideally, that translates to music being just as good for the patient on the table, who, if anaesthetized, can't hear it.
Dr. Karen Allen, a psychologist at the State University of New York-Buffalo, asked surgeons to perform nonmedical tasks while listening to music and monitored their heart rate and blood pressure while they worked.
"When they chose the music, regardless of what kind of music it was, they performed better," Allen says. "When someone else picked the music, they did worse. It might have something to do with the personality of most surgeons. There's a big control factor there. And we were told by several surgeons that the OR is not a democracy."
When Dr. Dan Reilly operates, the other members of the surgical team get a vote on the day's musical selections.
"But it's like with my kids at home. Their vote doesn't count," he says.
In Reilly's operating room, you'll usually hear Jimmy Buffett in the background.
Reilly, a hand and shoulder surgeon with Hand Surgery Specialists Inc. and Good Samaritan Hospital, has about 8½ hours of Buffett - no songs repeated - on his iPod. He also likes classic rock.
"Despite what my nurses think, I do have a wide variety of music, but it's all from 20 years ago, 'cause that's when they quit making good music," he says.
It's all Sinatra, all the time, when Dr. Howard Melvin, an eye surgeon at Good Samaritan Hospital, is in the operating room.
"I need something relaxing. I do very intense surgery," he says.
Some days, Dr. Robert Bohinski wants to hear Mozart in the operating room. Other days, only Guns N' Roses will do.
"Sometimes it just depends on what team we have that day, whether it's an older team or a younger team," says Bohinski, a neurosurgeon at University Hospital. "Usually it's just a gut feeling."
When things aren't going well or the surgeon needs complete concentration, the music gets turned off.
"For the delicate parts of brain surgery when we're under the microscope, I don't listen to music. It's too distracting. When I'm resecting a deep brain tumor, I need to focus," Bohinski says.
Dr. Charles Mehlman, a pediatric orthopedic surgeon at Cincinnati Children's Hospital Medical Center, chooses music according to the intensity of the procedure.
"When there's serious stuff, there's serious music," Mehlman says. "For the more routine stuff, it can be more fun music, like Dean Martin or Frank Sinatra."
Dr. Michael Thomas, a fertility specialist and director of the Center for Reproductive Health at St. Luke's West, listens to everything from Heart and James Taylor to Arrested Development and Maroon 5.
He likes driving rock beats, like Bruce Springsteen, for clearing fallopian tubes "so you can blast out all that endometriosis," he says.
And during infertility surgeries and embryo implantations, you'll hear Luther Vandross and Barry White crooning and breathing heavy.
"They've helped other people get pregnant without our help, so we're trying to use them to our patients' advantage during the procedures," he says.
There are two people in the operating room besides the surgeon who get input on music.
One is the patient. If they're going to be awake for the procedure, they can bring in their own music or choose from the surgeon's collection. They also can choose the music they'd like to hear while they're going to sleep.
The other is the anesthesiologist, who at least gets to order the music turned down or off while he or she listens for the patient's vital signs.
"It has to be soft enough they can hear the patient's heartbeat," Reilly says. "But they do have a stethoscope they can stick in their ear."
Dr. William Hurford, chairman of the department of anesthesiology at the University of Cincinnati College of Medicine, compares OR music to background music in department stores.
"We can basically block it out and listen to the patient and the monitors," he says.
Hurford, incidentally, likes quiet jazz.
Mehlman lets his patients' parents choose the music that will be played during their children's surgeries.
Mehlman also lets teammates choose songs when it's time to close - the operation is done and it's time to stitch everything up.
"Closing music is where it's at," he says. "The intense, scary, dangerous part is over, and you're changing gears."
E-mail pofarrell@enquirer.com
Print Go back Copyright 2005, The Enquirer

Another ad for essays.

Residency Personal Statements

--Article courtesy of Accepted.com, Application Essay Editing Service

To get into medical school, you explained why you wanted to be a physician. Now that you're an M.D., you need to secure that critical residency interview so you can show what you've got. To that end, your personal statement should give the residency committee a taste of what you're all about, and make them want more.

Easier said than done? Here are some of the critical pieces of a residency personal statement to get you started.

• Focus on the Specialty
• Focus on Your Strengths
• Focus on the Program
• Tips for Better Writing
• Need more Help?

Focus on the Specialty

Your rotations let you sample each medical specialty. By now, you should have a clear idea which one you want to pursue. Tell the residency committee how you reached that decision. What convinced you that you wanted to know more about neurology, and that you could never see yourself setting broken bones? What is it about delivering babies that thrills you more than caring for them after they're born? Use anecdotes to illustrate your story and bring out your unique experiences and perspectives. Most importantly, where do you see yourself in the future? Make your choice unambiguous and your commitment undeniable.

Focus on Your Strengths

You've gained valuable technical skills and exposure to clinical practice, but so have all your classmates. Which of your unique qualities will make your #1 residency program rank you as their #1 choice? Your personal experiences, both in medical school and outside, reveal a lot more about you than your C.V. and USMLE step exams. A good way to think about this is in the context of what's needed for that specialty. Will the listening skills you developed in college debate help you as a family practitioner? Have your quick reflexes, honed through years of playing piano, prepared you for the technical dexterity you'll need in emergency medicine? Will your teamwork skills developed as captain of your soccer team improve your coordination as part of a surgical team? Select specific examples that demonstrate your strengths and make your essay come alive.

Focus on the Program

You obviously don't want to write about your love for pediatric medicine if you're applying for a surgical residency program. What's less obvious is that you can: and should: write about the specific advantages of a research-oriented residency program in one essay and the benefits of a purely clinical experience in another. You can even write a different personal statement for every program. It sounds like a lot of extra work, but don't underestimate the bonus points you can get for this approach. Tailoring your essay to specific programs or types of programs demonstrates that you've done your homework and are genuinely interested.

Tips for Better Writing

Now that you have an idea what to write about, you need to know how to write it. Your tone of voice should be personable, but professional. Your story should be interesting and draw the reader into the story with specific examples, but use humor sparingly. Throughout your writing, keep your purpose in mind: you're trying to land the interview, not detail every aspect of your medical school training or research project.

Need More Help?

For more tips on writing your residency statement, get help from Accepted.com's experienced editorial staff. We can help you from the beginning or polish what you've already written. Either way, you'll get a personal statement that makes you shine!

By Cydney Foote, Accepted.com Senior Editor

Copyright Accepted.com 2003

Still more on personal statements

Well by now most readers will have correctly come to the conclusion that the idea of personal statement editing, ghost writing, etc. is an issue with me.
Here is an example of an ad for one of the internet services - see how slick it is!
Residency Personal Statement Services
After evaluating recommendations, transcripts, and test scores ad inifinitum, busy Program Directors use the residency personal statement to decide between applicants with very similar backgrounds and USMLE scores. While a strong residency statement will help you land an interview, a weak one will ensure that you don't.
Your residency statement must address why you became interested in your chosen specialty, what you can contribute to a given program, and how you intend to realize your professional goals. In addition, you must convincingly present evidence of your intellectual and personal credentials while demonstrating your motivation, determination, integrity, common sense, reliability, and personal capacity to excel in a challenging residency program. IMG candidates also must establish their English language ability.
While this may seem like a lot to achieve in a single essay, you have the benefit of control. EssayEdge will give you an advantage in the ultra-competitive residency application process by editing your essay to perfection. Our professional, Harvard-educated editors have read thousands of these statements and will edit your essay with an objective eye, ensuring that your residency application gets noticed.
For more information on EssayEdge's industry-leading personal statement services for residency applicants and our customers' overwhelming success in the residency program application process, please use the right-hand menu. For detailed service descriptions, please select a link below.

Another person who still has the Joy of Surgery

Hi folks, well I found this nice information about the joy of surgery on another website and felt compelled to share it here.

http://www.ctsnet.org/sections/residents/newhorizons/article-1.html
By Harold C. Urschel, Jr. MD
In 1995 Hal Urschel, MD, past president of the Society of Thoracic Surgeons, served as the Schuster Visiting Professor at The Brigham and Women's Hospital and Harvard Medical School. During that visit he delivered Surgical Grand Rounds, and his address was entitled "Let's Bring the Magic Back". His remarks were insightful and stimulating, and they are pertinent to many of the issues facing the profession of Cardiothoracic Surgery today. We are pleased to reproduce them on CTSNet.-Dr. Walter Merrill

Let's Bring the Magic BackBy Harold C. Urschel, Jr. MD

TWO YEARS AGO ALLEN GREENSPAN WAS THE KEYNOTE SPEAKERAT HARVARD’S COMMENCEMENT,
- WHETHER CONSIDERING GLOBALIZATION OR INDIVIDUALRELATIONSHIPS,
HE DEEMED THE MOST CRUCIAL CONDITION FOR SUCCESS WAS
- TRUST.
FOR THE PAST 8 YEARS IT HAS BEEN SORELY LACKINGNOT ONLY FROM ECONOMIC TREATIES, BUT WITHIN OUR FOREIGN POLICY
TRUST IS ALSO FUNDAMENTAL TO THE DOCTOR-PATIENT RELATIONSHIPAND HAS BEEN ERODED SIGNIFICANTLY BY THE MULTIFACETED THIRD PARTY INTERFERENCE.
THE EROSION OF DOCTOR-PATIENT TRUSTHAS PROVOKED SEVERE DEPRESSION AND “CREPE HANGING” IN PROFESSIONS.
WHAT HAPPENED TO THE “JOY OF SURGERY” (CLEM HIEBERT)
“THE MAGIC STUFF,THE GRAIL THAT ONCE MOVED EVERY DOCTOR IN THIS ROOMTO BECOME A SURGEONAND THAT EVEN NOW BECKONSTHROUGH THE JADING MISTOF TEDIUM AND TIME.STRIP AWAY THE CORRUPTING DULLNESSAND LOOK AFRESH AT OUR PROFESSION.I STILL CONTEND THAT IT IS THE MOST SPLENDIFEROUS OF ALLPROFESSIONS.”
WHY DID WE GO INTO SURGERY?
WE WANTED TO HELP OTHER PEOPLE AND WE WANTED TO MAKE ADIFFERENCE.
CERTAINLY THE DECISION WAS NOT MADE BECAUSE OF DOLLARS AND CENTS.
SURGERY EMBODIES THE SCHOLARSHIP OF SCIENCE,
THE SKILL OF A FINE ATHLETE,AND THE NECESSITY TO MAKE A PRECISE DECISION– THE SURGEON IS THE “FIGHTER PILOT” SO TO SPEAK OF OURPROFESSION.
WHEN I WAS IN SCHOOL HIPPOCRATES’ APHORISM, CHIZELED IN STONEON BLDG D, PRECISELY CHARACTERIZED THE SURGEON’S DAILY DILEMA:
“LIFE IS SHORT.THE ART LONG.THE OCCASION INSTANT.THE EXPERIMENT PERILOUS.AND THE DECISION DIFFICULT.”
MY BOOT CAMP TRAINING WAS TOUGH – SACRIFICE WAS PRIMARY.
AT THE HOSPITAL.
MY PATIENTS ALWAYS CAME FIRST .
MY WIFE, MY FAMILY, MY EMOTIONS ALWAYS REMAINED SECOND –36 HOURS ON, 12 HOURS OFF, FOR $25.00 A MONTH.
ONCE WHEN I CAME HOME ON A RARE WEEKEND, TO MY TWO SONSWHO HAD BEEN GIVEN TOY RAZORS FOR CHRISTMAS I SAID, “LET’S SHAVE TOGETHER.”
THEY IMMEDIATELY BEGAN TO SHAVE THEIR LEGS. THAT PRETTY MUCH SUMMARIZED MY INFLUENCE ON THE FAMILY ATTHAT TIME.
IN THOSE DAYS OUR POSITION WAS REVERED“THERE ARE MEN AND CLASSES OF MENTHAT STAND ABOVE THE COMMON HERD-THE SOLDIER, THE SAILOR, THE SHEPHERD NOT INFREQUENTLY,THE ARTIST RARELY, RARELIER STILL THE CLERGYMAN,THE PHYSICIAN ALMOST AS A RULE.
HE IS THE FLOWER SUCH AS IT IS OF OUR CIVILIZATION ANDWHEN THAT STAGE OF MAN IS DONE WITH ANDONLY TO BE MARVELED AT IN HISTORY, HE WILL BE THOUGHT TO HAVE SHAREDAS LITTLE AS ANY IN THE DEFECTS OF THE PERIODAND MOST NOTABLY EXHIBITED THE VIRTUES OF THE RACE.”
ROBERT LOUIS STEVENSON
I WOULD HOPE THAT IS STILL TRUE
WHO ARE OUR HEROES?
I WILL GIVE YOU A FEW OF MINE – WHILE YOU THINK OF YOURSWHAT LESSONS OF THEIRS WILL HELP?
DR. CHURCHILL ALWAYS FELT THAT“WE STAND ON THE SHOULDERS OF GIANTS,WE ARE CUSTODIANS OF A TRADITION. KNOWLEDGE IS HANDED TO US AND WE MUST PASS IT ON, SCRUBBED CLEAN, SO AS TO LEAVE THE PLACE BETTER AND BRIGHTER THAN WE FOUND IT. THINK OF YOUR HEROES – HOW CAN THEY HELP US?”
CHURCHILL FELT THAT THE MAIN STRENGTH OF THE SURGEON RESTED IN HUMANISM.
EINSTEIN, ONE OF HIS HEROES, ARTICULATED MANY OF CHURCHILL’S PRINCIPLES.
“TIME DOES NOT EXIST - THE DISTICTION BETWEEN THE PAST & FUTURE IS AN ILLUSION.”
ONE OF OUR MAJOR SATISFACTIONS AND COMPLIMENTS IS THE TRUST THAT OUR PATIENTS COMMIT TO US BY PLACING THEIR LIVES IN OUR HANDS FOR CARE. THIS IS WHAT MAKES OURS A PROFESSION, AND NOT A TRADE.
OUR BOND IS WITH OUR PATIENTS, SURGERY IS AN IRREVOCABLY INVASIVE REMEDY WHICH LINKS PATIENTS WITH US MORE CLEARLY THAN OTHER AREAS OF MEDICINE. DECADE’S LATER PATIENTS MAY RECALL THE VERY DATE OF THE EVENT, ESPECIALLY IF WE HAVE ADDED CARING TO THE CURING.
IN TRYING TO EXPLAIN WHY SOMEONE GETS THE NOBEL PRIZE JOE MURRAY – ANOTHER ONE OF MY HEROES TOLD ME THE LAST TIME I WAS HERE,
IT’S NOT JUST ONE GOOD IDEA CARRIED TO FRUITION – BUT RATHER A SERIES: THAT DEVELOPS A SYSTEM OF CARE
IN HIS CASE: RENAL TRANSPLANT: IDENTICAL TWINS – (MY 3rd YR HMS)
RELATED DONOR CADAVER
JOE IS A GREAT EXAMPLE OF EINSTEIN’S CONVICTION
“IMAGINATION IS STRONGER THAN KNOWLEDGE,MYTH IS MORE IMPORTANT THAN HISTORYDREAMS ARE MORE POWERFUL THAN FACTSHOPE ALWAYS TRIUMPHS OVER EXPERIENCELAUGHTER IS THE ONLY CURE FOR GRIEFLOVE IS STRONGER THAN DEATH.” - EINSTEIN
IN 1985 DICK BASS ASCENDED MT EVEREST AND BECAME THE FIRST PERSON TO CLIMB THE SEVEN SUMMITS - THE TALLEST MOUNTAIN ON EACH CONTINENT HE TOOK US TO MT. EVEREST IN 1987 TO PUT THE 1ST AMERICAN WOMEN ON THE SUMMIT AND AS ONE OF MY HEROES SAID:
“OUR DOUBTS ARE TRAITORS, AND MAKE US LOSE THE GOOD WE OFT MIGHT WIN, BY FEARING TO ATTEMPT.”
JOHN KNOWLES FELT
"HUMOR IS ESSENTIAL IN OVERCOMING MONUMENTAL CHALLANGESMANKIND’S MOST ENDURING AVENUE TO EMPATHYSHARED INSIGHT BINDING FAMILIES, FRIENDSAND EVEN STRANGERS TOGETHERSTARK, PAINFUL TRUTH DELIVERED IN WORDS OFAFFECTION AND ABIDING TRUSTSHUNS POMPOSITY, SHAM AND ALL FALSEHOODHE THINKS IT’S THE BROADEST EXPRESSIONOF HUMAN FAITH THAT WE HAVE"
“WHEN I DIE I WANT TO GO PEACEFULLY, LIKE MY GRANDFATHER DID,IN HIS SLEEP,NOT SCREAMING LIKE THE OTHER PASSENGERSIN THE BACKSEAT OF HIS CAR.” (HCU)
DICK BASS LIKE RICHARD SWEET REMINDS US THAT: - THE MAJOR GOAL OF THE SURGEON AS THE MOUNTAINEER IS TO “OVERCOME DIFFICULTY.”
STANLEY MARCUS - FRIEND PATIENT WORLD TRAVELING COMPANION
HAS BEEN A CONSTANT INSPIRATION AND HIS
LEGENDARY BOOK:
– QUEST FOR THE BEST
“- THE RIGHT TO BELIEVE FREELY. TO BE A SLAVE TO NO MAN’S AUTHORITY. IF THIS BE HERESY – SO BE IT. IT IS STILL THE TRUTH TO GO AGAINST CONSCIENCE IS NEITHER RIGHT NOR SAFE. I CANNOT – WILL NOT – RECANT. HERE I STAND – NO MAN CAN COMMAND MY CONSCIENCE.
MARTIN LUTHER
- MARTIN LUTHER’S FAMOUS CREDO IS ONE OF THE NOBLEST EVER MADE BY MAN. IT REPRESENTS MY PERSONAL PHILOSOPHY EXACTLY. IT IS BY MY SUBSCRIPTION TO IT THAT I HOPE TO BE REMEMBERED.”
STANLEY MARCUS
REMINDS US THAT:WE MUST INSIST ON “WHAT IS BEST” FOR OUR PATIENTS -AS THEIR PRIMARY ADVOCATE.
THE EDITOR OF THE DAYTON FLYER NEWSPAPER WAS CHAGRINED AT REPORTING ONLY MURDERS, TRAGEDY AND DEPRESSION - MUCH AS WE SEE TODAY.IN THE LATE 1800’S HE STARTED PUBLISHING ON THE FRONT PAGE A STORY TWO OR THREE TIMES A WEEK OF A GREAT HERO, INVENTOR, OR SCIENTIST. THIS CONTINUED FOR FORTY YEARS – THE REST IS HISTORY. DAYTON HAS PRODUCED MANY MORE INVENTORS, LEADERS AND SCIENTISTS THAN ANY OTHER MAJOR CITY IN THE COUNTRY PER CAPITA.
YOU’RE FAMILIAR WITH THE WRIGHT BROTHERS, AND THOMAS EDISON, BUT WHAT ABOUT CHARLES KETTERING? HE DESIGNED A MOTOR TO OPEN THE CASH REGISTER DRAWER FOR NCR WITHOUT THE CRANK.HOWEVER HIS MOST DRAMATIC ADAPTATION ELIMINATED THE CHAUFFEUR’S FRACTURE.HOW MANY KNOW WHAT THAT IS? THIS WAS A FRACTURE OF THE RADIUS STYLOID AFTER “CRANKING THE MODEL T TO START THE ENGINE” – THE SELF-STARTER. HE USED THE SAME MOTOR OF THE CASH REGISTERTO REVOLUTIONIZE AND POPULARIZE THE CAR INDUSTRY.
SOME OF YOU REMEMBER: TO START THE CAR YOU HAD TOSET THE SPARK & THROTTLE – JUMP OUT, TURN THE CRANK – RUN BACK, RESET THE SPARK & THROTTLE BEFORE IT STALLED. THE SELF-STARTER DID MORE TO EMANCIPATE WOMEN’S LIBERATION THAN SUSAN B. ANTHONY.
KETTERING SUBSEQUENTLY GAVE MUCH OF HIS FORTUNE TO SLOAN- KETTERING MEMORIAL CANCER HOSPITAL IN NEW YORK.
OFTEN A SOLUTION TO A SIMPLE PROBLEM MAY HAVE A MUCH WIDER APPLICATION ONE ESSENTIAL TO SUCCESSFUL SYSTEMS DEVELOPMENT.
ROSS PEROT OFFERED TO HELP IN 1994 AGAINST CLINTON’S SOCIALIZATION OF MEDICINE.BETSEY & I BROUGHT HIM TO THE KENNEDY SCHOOL OF GOVERNMENT (KSG) AT HARVARD FOR A 2 DAY ORIENTATION - MEDICAL - PUBLIC HEALTH – LAW – BUSINESS – TO BRING HIM UP TO SPEED.
ROSS PEROT CHALLENGED US DURING THE CLINTON HEALTH CARE SCARE TO “PUT OUR PATIENTS FIRST ” AND PROVIDE LEADERSHIP FOR HEALTH CARE REFORM. FEW OF US COMPLIED.WE ARE VICTIMS OF OUR PERSONALITIES AND OUR TRAINING. WE DON’T FOLLOW ANYONE. IT WAS THE RESTAURANT OWNER AND WORKERS’ UNION WHO SUCCESSFULLY LOBBIED AND DEFEATED THE CLINTON HEALTH REFORM CHALLENGE.LEADING SURGEONS IS LIKE HERDING CATS. – ONE OF OUR MAJOR HURDLES TO DEVELOP SYSTEMSGIVING OUR PATIENTS PREMIERE BILLING IS CARDINAL TO FUTURE SUCCESS.
BASED ON THE SUCCESS OF PEROT’S ORIENTATION AT THE KSG, BETSEY AND I ARRANGED A HEALTH POLICY COURSE THERE TWO TIMES A YEAR FOR CARDIOVASCULAR LEADERSHIP AND INDUSTRY.
PEROT POINTED OUT:“THERE ARE AT LEAST THREE AREAS IN WHICH AMERICA EXCELS IN THE WORLD.”“OUR FARMER IS THE BEST -ONLY 6% OF OUR POPULATION IS REQUIRED TO FEED ALL OF US -IT TAKES 65% OF RUSSIANS AND 75% OF CHINESE FARMING –WE BUILT THE FIRST, AND BEST AIRPLANES, IN THE WORLD.OUR MEDICINE AND RESEARCH ARE WORLD-CLASS. PEOPLE COME FROM ALL CORNERS OF THE EARTH FOR OUR HEALTH CARE. ALL THREE OF THESE SHINING STARS ARE BEING CRIPPLED BY THE SAME FORCE – THE PARASITIC MIDDLEMAN .”
WE MUST REDUCE THE POWER OF THE MIDDLEMAN. -THE INSURANCE COMPANY. WHO HAS THE TALLEST BUILDING IN EVERY CITY? – HE WHO CONTROLS THE DATA AND INFORMATION CONTROLS THE SYSTEM.
HENRY CISNEROS DESCRIBED THE INEVITABILITY OF CHANGE,“IF NO ONE LIFTS A FINGER OR NO ONE CARES, THINGS CHANGETHE HUMAN BODY GROWS OLDER, MACHINES GROW RUSTY,FRIENDSHIPS FALL APART, FOUNDATIONS BEGIN TO SETTLE.LEFT UNATTENDED, THE DYNAMIC OF CHANGE IS ‘DECLINE’ ”.THE TRICK IS TO CONVERT CHANGE INTO A POSITIVE FORCE AND THAT TAKES POSITIVE ACTION. GENERAL DOUGLAS MACARTHUR MADE IT VERY CLEAR:
“THE HISTORY OF THE FAILURE OF WAR CAN BE SUMMED UP INTWO WORDS: TOO LATETOO LATE IN COMPREHENDING THE DEADLY PURPOSE OF APOTENTIAL ENEMY;TOO LATE IN REALIZING THE MORTAL DANGER;TOO LATE IN PREPAREDNESS;TOO LATE IN UNITING ALL POSSIBLE FORCES FOR RESISTANCE;TOO LATE IN STANDING WITH ONE’S FRIENDS”.
WE MUST RECAPTURE THE:
“THE JOY OF SURGERY THE MAGIC STUFF, THE GRAIL THAT ONCE MOVED EVERY DOCTOR IN THIS ROOM TO BECOME A SURGEON, AND THAT EVEN NOW BECKONS THROUGH THE JADING MIST OF TEDIUM AND TIME. STRIP AWAY THE CORRUPTING DULLNESS AND LOOK AFRESH AT OUR PROFESSION. IT IS THE MOST SPLENDIFEROUS OF ALL PROFESSIONS.”
IT’S TIME TO TAKE THE MAGIC BACK .
Publication Date: 27-Aug-2004Last Modified: 18-Jul-2005

Lifelong learning

Well today I had the opportunity to talk to the surgery residents about lifelong learning. The context was the Department of Surgery's new requirement that residents complete a project and prepare a manuscript prior to promotion to the chief resident year. I am both optomistic and realistic about hte process. The most important thing will be seeing the residents enlarge their skills for self-directed learning. This will ultimately make them better surgeons. JTE.

More on personal statements

Well, I have been exploring this ethical question even more. Additional information reveals that ghost writing personal statements is a booming business. There are internet sites that will help high school students write for college applications, college students write for graduate and professional schools and medical students write for residencies and residents write for fellowships. How is it possible that we as a society have reached this point - ghost writing personal statements. How can we stop this? Should we even try to stop this from occuring? Just being rhetorical, but if anyone has comments they are welcome as always. JTE.

Hunter, Lister, Willis ????

Question = What do Hunter, Lister and Willis have in common?
Answer = All buried in Westminster Abbey.

Ethics Senior medical students applying for residencies

Well, this is an interesting topic = the ethics of residency applications. Recently one of the very good students form the Senior class asked for my assistance in the personal statement aspect of the process. Here is my email response:
Yes, ...... I do remember you. Thank you for honoring me with the request to be of assistance. However, this request to help with the personal statement on the residency application is a very difficult issue to deal with for any faculty member. First because it is a personal statement and should be just that a personal statement! However, as someone who wants only the very best for you, I am subject to the natural desire to help polish the written product. Fortunately, your personal statement you sent me is very good. In most cases, I have found that simply by encouragement and discussion, students are able to work through the revision process without editorial assistance. Furthermore, it is only one part of the overall application. Reference letters, grades and the interview will all play a part. Now to the personal statement. Re-read it carefully and answer the important question - after reading this what does it say about me? Is it reporting my experiences? Is it reporting how I feel about my experiences ? Is it both? Is it neither? What about my personal statement would make me a desireable candidate? What is the one best reason a Surgery Residency Program should pick me? Have I conveyed that one best reason? When lying in bed alone at night after a hard day, what do I hold on to as my best quality? Did it shine through in my personal statement? Remember in the final analysis your personal statement is more about how you think of yourself than how others think of you! Thanks again for the request and reply with your thoughts. All my best. JTE.

Well, after writing that response, I began checking with other faculty and students. To my shock I discovered there is one faculty wife who actually ghost writes personal statements. Also, I found that there are faculty who gladly apply red pens and editorial supervision. It is my view that ghost written personal statements constitute blatant fraud and I would recommend rejection of any candidate guilty of same. What about faculty? I do not know of any censure available for them. This would seem to boil the selection process down to a review of grades, standardized scores, and letters of reference. Truly the phrase caveat emptor was never more appropriate!. JTE

Paul Loeb

SUBJECT: HOPE FOR THE LONG HAUL In these tough political times, I thought you’d be interested in a book that lifts the fog of political despair that envelops so many these days--"The Impossible Will Take a Little While: A Citizen's Guide to Hope in a Time of Fear,” named the #3 political book of Fall 2004 by the History Channel and the American Book Association, and winner of the Nautilus Award for the best spiritual social change book of the year.The Impossible creates a conversation among some of the most visionary and eloquent voices of our times: Think Nelson Mandela, Maya Angelou, Arundhati Roy, Tony Kushner, Václav Havel, and Howard Zinn. Alice Walker, Jonathan Kozol, Diane Ackerman, Susan Griffin, and Marian Wright Edelman. Cornel West, Terry Tempest Williams, Jim Hightower, and Desmond Tutu.
With this book, editor Paul Rogat Loeb, whom Susan Sontag has called "a national treasure" for his work on courage and conscience, builds on his activist classic, "Soul of a Citizen." He explores what it's like to go up against Goliath, whether South African apartheid, the iron fist of Eastern European dictatorship, or Mississippi segregation. These stories don't sugarcoat the obstacles. But they inspire hope by showing what keeps us keeping on--even when the odds seem overwhelming. They replenish the wellsprings of our commitment.If you care about change in a world where most people are told their voices don't count, think of this book as a gift to yourself---bread for the journey to keep on working for and sustenance to return to again and again when your spirit begins to flag.Find out more by visiting www.theimpossible.org. You'll find excerpts from the book, wonderful reviews, Paul’s national speaking schedule, and live interviews. There’s also information on classroom use including sample study questions, and on Loeb’s previous underground bestseller, Soul of a Citizen.
Bill Moyers writes, "You are part of what's good about this world and I admire your work very much. This book can even make one hopeful about the future despite so many signs to the contrary." Barbara Ehrenreich says, "For anyone worn down by Bushism, The Impossible Will Take a Little While is a bracing double cappuccino!" And Arianna Huffington writes, "Put away your Prozac and pick up The Impossible Will Take a Little While." Please forward it to anyone who could use a song of hope in these difficult times. And do your soul a favor by reading the book.

THE IMPOSSIBLE WILL TAKE A LITTLE WHILE: COMMENTS & REVIEWS

History Channel & American Book Association's #3 political book for Fall
2004

"This might possibly be the most important collection of stories and essays
you will ever read." --American Book Association & History Channel
top-10 Fall 2004 political book list

"Paul Loeb brings hope for a better world in a time when we so urgently need
it."--Millard Fuller, founder, Habitat for Humanity

"A much needed salvo against despair."--Psychology Today
"Hopeful, inspiring and motivating...May well be required reading for us
all."--Sierra Club magazine
“Deeply moving and motivating… a retinue to be reckoned with; a plethora of commentary from those dedicated to the concept of a better world”—Baltimore Sun

"As I read these stories, I am reminded yet again of the incredible power we
have as individuals and the multiplication of that power when we come
together. Thank you for this book of inspiring writing." --Joan Blades,
cofounder, MoveOn.org


“Think of this as a devotional for those who subscribe to the theology of liberation and social justice. Will resonate with anyone struggling with despair and doubt.”—Dallas Morning News

"Stunning insights...educational and inspirational."--Seattle Times

"A stirring collection of essays aimed at people who still want to believe
that ordinary people can change the world." --Atlanta Journal Constitution

"This inspiring collection is such a song of hope in these difficult
times--Bonnie Raitt

"For anyone worn down by Bushism, The Impossible Will Take a Little While is
a bracing double cappuccino!"--Barbara Ehrenreich

"An anthology of some of the most powerful voices of our time."--Boston
Globe

"A magnificent anthology celebrates hope, guts, and the power of taking
action.... Loeb has done us a great favor [and] compiled for us the words of
49 of the most gifted and heroic men and women of our time, 49 testimonials
to stamina and compassion in the face of seemingly insurmountable odds, 49
reasons to keep hope alive in this time of frustration and fear, 49 ways to
take action..."--Pam Houston, Oprah magazine [Lead Review]

"An extremely important effort."--John Kenneth Galbraith

"A wonderful book, with some extraordinary folks contributing. It reminds us
that darkness always comes before the dawn."--Reg Weaver, president,
National Education Association

"Stop worrying, stop feeling sorry for humanity and read 'The Impossible
Will Take a Little While.'"--Chicago Tribune

"An intelligent, impressive compendium of ideas and feelings that, if
implemented, will lead to a far more civilized society." --Peter Matthiessen

"An indispensable anthology of hope and inspiration. Put away your Prozac,
and pick up The Impossible Will Take a Little While." --Arianna Huffington

"Refreshingly empowering, healing, and amazingly inspirational. It touches
the imagination, retrieves the faith, and is desperately needed by our
country to provoke new hope and meaning. It is a glass half full for the
cynic and the fearful, a compilation of vision for the complacent, and an
antidote for the despondent--truly a must read for everyone." --Steelabor,
United Steelworkers of America

"A book of essays meant to inspire people."--Christian Science Monitor

"Reading this hymnbook of hope, one's heart cannot help but sing. I am moved
and inspired by this magnificent book's rich stories and insights. They
water the fragile, precious seed of hope, from which everything we love
grows." --Vicki Robin, author, Your Money or Your Life

"Just what the doctor ordered for these depressing times: a massive infusion
of hope, written in the clearest and most inspiring prose. Do your soul a
favor and read this book." --Kevin Danaher, cofounder, Global Exchange

"A powerful chorus of hope. Loeb introduces us to a community of heroic
individuals who by their actions sustain themselves and can help inspire the
rest of us."-- Bill Meadows, president, Wilderness Society

"Captures the way the fight for decency can change people and change
circumstances, even when victory is still in the distance--Rich Trumka,
secretary--treasurer, AFL--CIO

"Everyone who believes in our humanity and the ideal of justice for all, but
feels despair by the direction the world has taken since 9/11, will find
their faith in our ability to serve the common good restored by Paul Loeb's
symphony of powerful voices." --Charles Johnson, National Book Award winner,
author of Middle Passage

Gang mayhem

Well, my new Chief resident got tested to the hilt on one of the first on-call nights. We were the on-call team for a night of gang violence. 2 stabbings and 4 gunshot victims almost simultaneously. The recent ATLS course including the triage scenarios was put to the full use possible. Anyway, we repaired an aorta, brachial artery, did a colostym, tube thoracostomy, etc. all in about 3 hours. The OR nurses and the OR nurse on-call team were able to respond as well. After a long hard night of operating continuosly, there is still the Joy of the Surgery because we save lives. JTE.

End of Academic Year

Well the end of the academic year approaches. Graduation of chief residents, etc. Another July 1 of new interns, etc. An truly academic renewal. JTE.

Surgical Risk

Well readers here is another installment. This time about the age old question - surgical risk. As we see more and more patients who are beyond 75 years of age, the question of risk of surgery continues to be one which challenges everyone = patients, relatives, physcians. The Society for Decision Analysis has provided a forum for this discussion for decades and yet the very practical and useful information needed is still missing. The focus on outcomes research has added another dimension of confusion. As usual it is often from celebrities or famous individuals that an interest in areas of medicine are stimilated to public interest. The recent surgeries of former President Bill Clinton brought into focus the concept of institutional morbidity and mortality when the hospital he chose was exposed for its high mortality rate from the New York heart surgery data. The real problems are in narrowing the focus for individuals and unfortunately, we still can not do that very well yet.

Blue Ribbon Surgical Education

Dear Readers:
Here is a very important article.
I will be commenting on ot in the days to come. Just read it for now.

American Surgical Association Blue Ribbon Committee Report on Surgical Education: 2004 Haile T. Debas, MD; Barbara L. Bass, MD, FACS; Murray F. Brennan, MD, FACS; Timothy C. Flynn, MD, FACS; J. Roland Folse, MD, FACS; Julie A. Freischlag, MD, FACS; Paul Friedmann, MD, FACS; Lazar J. Greenfield, MD, FACS; R. Scott Jones, MD, FACS; Frank R. Lewis, Jr., MD, FACS; Mark A. Malangoni, MD, FACS; Carlos A. Pellegrini, MD, FACS; Eric A. Rose, MD, FACS; Ajit K. Sachdeva, MD, FRCSC, FACS; George F. Sheldon, MD, FACS; Patricia L. Turner, MD; Andrew L. Warshaw, MD, FACS; Richard E. Welling, MD, FACS; Michael J. Zinner, MD, FACS Ann Surg 241(1):1-8, 2005. © 2005 Lippincott Williams & Wilkins Posted 01/19/2005 Introduction American surgical education has a rich heritage, and its programs produce some of the best trained and most competent surgeons. Although surgery residency training has changed little since its formulation by Halsted at the beginning of the last century, surgery residency and fellowship programs continue to maintain high standards because they are highly structured, monitored, evaluated, and credentialed. At the dawn of the 21st Century, however, numerous forces for change are impacting medical education in general and surgical training in particular. On the one hand, the explosion of knowledge from the advances of science, systems, and information technology provide new opportunities to improve our training programs. On the other hand, as the public has become increasingly better informed about its healthcare needs and safety, its expectation has shifted and now increasingly demands advanced and specialized care. Contrary to earlier predictions of excess physicians by 2010, we appear to be on the threshold of a shortage in physician workforce. This impending shortage should be viewed in the context of Association of American Medical Colleges (AAMC) data, which show that the number of applicants to medical schools in the United States has declined by 25% since 1996. Now, nearly 50% of students entering medical school are women. The average U.S. medical student now graduates with a debt in excess of $100,000. Students of both genders are increasingly selecting specialties with more controllable lifestyles than general surgery. Furthermore, general surgery residencies experience an attrition rate of nearly 20%, primarily because of lifestyle concerns of residents. Major changes have occurred and more are foreseen in the practice of surgery. Much clinical care has moved from the inpatient hospital setting to the outpatient, and the length of stay for inpatients has significantly decreased. These shifts have resulted in a significant impact on both undergraduate and graduate medical/surgical education. Surgical care is moving from discipline-based to disease-based practice in which surgeons will increasingly practice within a team of experts. How do we train surgeons to be leaders of such multidisciplinary teams? Recognizing the multitude of changes taking place, and spearheaded by the Presidential Address at the 2002 annual meeting of the American Surgical Association (ASA), the ASA Council in partnership with the American College of Surgeons (ACS), the American Board of Surgery (ABS), and the Resident Review Committee for Surgery (RRC-S), established a Blue Ribbon Committee on Surgical Education in June 2002. The Committee was charged with examining the multitude of forces impacting health care and making recommendations regarding the changes needed in surgical education to enhance the training of surgeons to serve all the surgical needs of the nation, and to keep training and research in surgery at the cutting edge in the 21st Century. This report is based on the work done and consultations obtained by the ASA Blue Ribbon Committee over a 2-year period. The Committee quickly recognized the complexity of its tasks and how any major recommendation for change could provoke controversy among many stakeholders, including members of the committee itself. Gradually, however, the committee was able to arrive at a consensus. On a separate track, the ABS has come to similar conclusions on how to restructure the surgery training program. The Committee recognizes that its recommendations are just recommendations, but sincerely hopes that they will serve as an impetus for a concerted effort by the ACS, ABS, and the RRC to further refine and implement them. What is being recommended here is no less than a new surgical education system but one that takes place in the context of patient care. This will require major redesign of surgery residency training and allocation of sufficient resources to achieve the desired outcomes. Given that such an education system is essential not only for producing the next generation of highly trained surgeons, but also for enhancing the quality of the most advanced patient care in the nation's teaching hospitals and clinics, appropriate strategies need to be developed at the national level to implement the recommendations. The report is presented under the following headings: Surgical/Medical workforce Medical student education in surgery Resident workhours and lifestyle in surgery Residency education in surgery The structure of surgical training Education support and faculty development Training in surgical research Continuous professional development The Executive Summary highlights the conclusions and recommendations of the Committee. Surgical/Medical Workforce Issues Estimating physician workforce has proved to be a difficult, unreliable task. Nevertheless, a number of recent developments warn that a shortage in the surgical workforce may be already on us. In recent years, we have seen fewer applicants to medical schools and variable interest among medical students regarding general surgery as a career choice. The results of the 2001 National Residency Matching Program served as a wake-up call for the surgical community when there were 68 unfilled first-year positions for general surgery. Although since that year, the applicant numbers have returned to their original levels, the trend for the future is unknown. Close to 20% of trainees leave general surgery residencies to enter either other specialties of surgery or nonsurgical specialties with more predictable lifestyles. This attrition rate in the number of trainees in general surgery could have a significant impact on future workforce needs. In addition, the introduction of the 80-hour week regulation for surgical residents in July 2003 has created a yet undetermined need for an enlarged nonphysician workforce in the provision of surgical clinical care within the hospital. In June 2002, the AAMC altered its position on the physician workforce, which until that time had supported the 1997 consensus document that predicted a physician surplus by the year 2000. The new AAMC position is as follows: In the 1980s and 90s, workforce analysts and public policymakers, with few exceptions, predicted that the United States would experience a substantial excess of physicians by the beginning of the 21st century. In light of these analytical studies, the AAMC and other national organizations recommended steps to reduce physician supply to obviate the predicted surplus. It now appears that this predication may have been in error. Furthermore, the AAMC has concluded that no definitive conclusions can be drawn about the adequacy of the workforce, nor can specific recommendations be made about the rate of supply of new physicians. The Association has, therefore, modified its physician workforce position. These positions reflect the present uncertainty but acknowledge the reality that a shortage of physicians is more consequential for society as a whole than is excess; a shortage of physicians would undeniably make access to care more problematic for all citizens, especially the disadvantaged. In our opinion, a shortage of surgeons at a time of great international instability and war would be particularly problematic to the nation. It is necessary, therefore, that studies be undertaken to determine in greater specificity the national supply and demand for surgeons in the different specialties. In the estimation of Cooper,[1] based on economic projections, a severe physician shortage is predicted, particularly in the surgical specialties. Nonphysician healthcare workers (physician assistants, nurse practitioners, technicians, and so on) will play an increasing role in providing care to patients. Although they will comprise an important component of the future surgical team, their impact on mitigating the shortage of surgeons will be minimal. An important factor in physician workforce projections, particularly in surgery, is the role of women. Cooper[1] points out that fewer men are obtaining undergraduate degrees, and at the present, women comprise 60% of college undergraduates and 50% of graduating medical students. Historically, women have not chosen general surgery residency in large numbers, and in 2003, they comprised less than 30% of the total number of matching students. Unless surgical training and careers in surgery are made more attractive to women, a pipeline problem may develop in the production of surgeons. Also, the aging American population will require greater access to surgical specialty care in the future. Recommendations If the predicted shortage of physicians and surgeons is confirmed: The infrastructure for medical student education should be expanded to produce more physicians. The number of trainees in general surgery and other surgical specialties should also be increased. Funding for this increase should come from IME and DME allocations. Also, a concerted effort must be made to recruit qualified women applicants. The global impact of continued dependence on international medical graduates must be carefully studied. A task force should be appointed to monitor the workforce needs of all surgical subspecialties on an ongoing basis using state-of-the-art methodologies. Medical Student Education in Surgery Traditionally, the priorities and expectations of surgery departments have been directed toward patient care and research. Surgery departments need to rededicate themselves to education to effectively address the learning needs of medical students, residents, and faculty. Surgical faculty and residents must become more involved in undergraduate medical education to develop and sustain in medical students an interest in a career in surgery. Surgery departments should be involved in the teaching of medical students in the first 2 years along with faculty members from the basic science disciplines. Particularly appropriate may be an increased involvement of surgical faculty as facilitators in many of the problem-based learning curricular components now part of many medical schools. Such involvement would not only enhance the education in the basic sciences by providing additional context and demonstrating relevance, but would also provide the students with early exposure to surgeon mentors. Most medical students make their specialty decisions by the end of the third year of medical school. The third-year surgery clerkships should provide students an exciting experience that will encourage them to consider surgery as a career. The development and understanding of the role of mentors is crucial. Often, the fourth year consists of relatively unstructured and poorly coordinated electives. Although there is value in providing students the freedom to engage in activities of their own choice, an opportunity is missed to use the fourth year more optimally and to possibly shorten the overall length of postgraduate training. Also, students need to develop technical proficiency in clinical skills laboratories before encountering patients. The technology and experience with skills laboratories is now sufficiently advanced to be indispensable in medical student education. Recommendations Departments of surgery should renew their commitment to education and develop surgical education centers that emphasize teaching expertise, education science, and education research. Such an endeavor should be coordinated through the Division of Education of the ACS, which should also provide supervision and set the standards. Recruitment of professional educators by surgery departments is strongly encouraged. These professionals would collaborate with the surgical faculty in designing education activities, promoting standards of evaluation, and pursuing educational research. Surgery departments should strive to make surgical clerkships and resident preparedness courses of the highest quality and meet the highest standards of teaching and evaluation. Surgical residents, who play a significant role in medical student education, should be offered opportunities to enhance their teaching skills and allowed sufficient time to serve as effective teachers and evaluators. A conscious endeavor to identify and encourage surgical role models is an example of what the ACS could develop. To assist with the transition from medical student to surgery resident, the Blue Ribbon Committee recommends that the Division of Education of the ACS should play a lead role in collaborating with the ACGME, AAMC, surgical boards, and selected medical schools to partially restructure the fourth year of medical school and develop a surgical prerequisite curriculum. This prerequisite curriculum would, without minimizing the breadth of the fourth-year education, permit those students electing a career in surgery to better prepare for surgical residency and ultimately perhaps even obtain credit that would shorten the length of their surgical training. Surgery departments with demonstrated faculty commitment, skills laboratories, and acceptable methods of instruction and evaluation should be allowed modification of the fourth-year curriculum for students pursuing surgery. Resident Work Hours and Lifesytle The ASA Blue Ribbon Committee endorses the recent regulation on the 80-hour week for residents and believes that the introduction of these regulations provides a unique opportunity to reexamine the entire system of surgical care and surgical education in the United States by: Defining a standardized, national curriculum for surgical education and training; Focusing surgical residency programs on education and patient care by eliminating hospital services without educational value (patient transport, phlebotomy service, secretarial work, and so on); Creating a training environment for residents that reduces fatigue and promotes improved lifestyles for the residents and their families, and provides flexibility for parenting; and Restructuring surgery training programs to produce the spectrum of surgical specialists that the nation requires to provide surgical care in all communities. Recommendations A carefully planned nationwide study should be conducted to determine the impact of the 80-hour week regulations on the operative experience of residents, on patients' safety and continuity of care, on resident education, and on satisfaction and quality of life. The Division of Education of the ACS should coordinate this effort with other national organizations and residency programs. Resources must be provided to hire the necessary nonphysician workforce that will provide the noneducational services that the residents will no longer perform. To sustain quality patient care as well as the quality surgical education, additional funding mechanisms should be developed to compensate for the additional work and stress of the teaching faculty. Such a strategy is key to retention of the teaching faculty. Resident services alone should not be used to treat the underserved in our cities. Local, state, and national governments need to accept their responsibilities in this area. The new educational paradigm should emphasize commitment to efficient patient care characterized by high quality and safety. Residency Education in Surgery The process for attracting, interviewing, and selecting medical students for surgical careers needs to be more efficient and user-friendly. Recommendations A realistic and valid system should be developed to describe each residency program and the surgical experiences it offers. Based on this system, residency programs may be categorized according to what type of surgeon each aims to produce. Surgical residencies should create greater diversity by actively recruiting women and underrepresented minority students. The surgical profession should urgently address the indebtedness of residents and design programs with more reasonable time duration and other methods of reducing debt such as scholarships and grants and federal debt-forgiveness programs. Every effort should be made to keep residents' salaries at a level sufficient to support standards of living appropriate to age and contribution. Basic topics that all surgical residents need to master need to be defined and should serve as the foundation for further training in the various specialties. This fundamentals of surgery curriculum should be modular and competency-based to allow incorporation into the overall educational programs of respective surgical specialties. The Division of Education of the ACS is taking the lead role in the development of this curriculum, which will be based on the ACS's Prerequisites for Graduate Surgical Education: A Guide for Medical Students and PGY1 Surgical Residents document. The ACS will collaborate in this endeavor with various organizations, including the Boards, RRCs, and program director organizations. Structure of Surgical Training There are many forces driving change in the nature and structure of surgical residencies. Among these are the explosion of knowledge in all surgical fields; new technologies for teaching and assessing surgical skills and for performing surgery; evolution toward multidisciplinary collaborations in patient care; progressive subspecialization; concern for quality and safety of patient care; emphasis on professionalism and competency; and higher expectations of patients. Regulatory changes have limited allowable work hours by residents and put additional stress on the ability to meet the service needs of hospitals as educational needs are given priority. Today's surgical resident is a different person. There are more women in surgical training, and residents have more education-related debt. Residents have greater concerns about their lifestyle and length of training. There is need to maximize efficiencies and minimize the duration of residency. It is increasingly apparent that as subspecialization in surgery continues to evolve and the appeal of broad general surgical practice diminishes, the illusion that a uniform training program purporting to produce competence in all areas is fading. One size no longer fits all. Uncommon case materials are less efficiently distributed when they are used to train individuals whose ultimate goals do not involve focus in these areas. Education research is pushing toward competence-based advancement, replacing time-in-service. Subspecialty fellowship training is at present largely unregulated, unsupervised, nonuniform, and uncertified. Research by residents during residency is too often for the sole purpose of attaining a clinical fellowship or to meet the needs of faculty for laboratory workers. A new paradigm is needed that promotes both the varieties of general surgical practice and the subspecialties that derive from general surgery. This training paradigm must achieve greater efficiency and use different methods to be able to accommodate the changing needs of surgical residents and surgery as it will be practiced. Recommendations Surgical residencies should be restructured to ensure that all trainees receive a common grounding in basic principles of surgical disease and patient care. There needs to be acceptance of the reality that most surgeons will confine the scope of their practices to meet definable goals. This should lead to earlier differentiation into goal-oriented specialty tracks. New teaching technologies (ie, simulators, virtual reality) and verification of competence at each training milepost should be introduced as they become validated and available. A goal should be to define a curriculum for surgical skills that must be acquired by surgical trainees outside the operating room before they begin to operate on patients. It is suggested that a modular format be developed to include a basic surgical core curriculum, and further training in either general surgery or a surgical subspecialty leading to the relevant, specific certification as shown in Figure 1. Furthermore, focused subspecialization would be available through postgraduate fellowships (ie, breast, endocrine, HPB, congenital heart, hand). An optional research module of not less than 2 years can either be interposed between the basic and advanced modules or taken at completion of the residency/fellowship for career development in conjunction with a first faculty position. The option to study for completion of an advanced graduate degree (PhD, MPH, MBA) may occur either after the basic module or after residency. Design, supervision, and certification of the new curricula and the training programs in which they will be used will remain the domain of the respective Boards, RRCs, and surgical specialty societies. It is understood that there will be manifold logistic challenges to implementation, including acceptance by the various stakeholders. Figure 1. Proposed schema for restructured surgical residency training. Many of the proposed tools have not yet been developed or are rudimentary. Problems such as logistical planning for training programs, possible instability of early career choices, funding, and unanticipated adverse effects on hospital utilization and surgical practices will need to be studied and managed. For these reasons among others, this proposal is offered as a goal to be explored, tested, and accomplished incrementally over a period of time. Education Support and Faculty Development A hallmark of American surgery departments and their faculty has been their unparalleled commitment to and pride in their trainees and training programs. To sustain and improve quality of training, the surgical faculty should develop expertise in education. Surgical leaders should be committed to incorporating high standards of education in medical student education, resident education, and continuing education. Specific financial remuneration of the faculty for their educational activities is often lacking. This fact combined with the greater demands on faculty for clinical productivity, the greater hassle in clinical practice they have to endure, and the time-consuming documentation requirements imposed on them by unfunded federal mandates (eg, PATH Audits, HIPAA) leave the surgical faculty with ever decreasing time to contribute to educational activities. Traditionally, departments of surgery have focused their priorities and expertise on patient care and research, and have not allocated sufficient resources to education. As a result, the use of contemporary educational principles and state-of-the-art evaluation methods is not widespread. In addition, educational efforts of the faculty are inadequately recognized and rewarded. The budgeted revenue for most surgery departments is derived from clinical practice, and only a small percentage comes from the medical school. This reality creates a disincentive for the faculty to participate in educational activities and particularly to engage in medical school admissions processes and curricular affairs. Surgery departments, therefore, need to develop a mechanism to enable faculty to devote more time in the nonrevenue-generating educational activities. We must accept that remuneration for activities such as education has to be seen as important as other professional activities. This will require education of the public and the payers. It may be possible to link such remuneration to compensation provided for administrative and regulatory demands. The surgical faculty is often more committed to resident training than to medical student education. Indeed, medical student education during clinical rotations has often been left to overburdened and fatigued residents. Furthermore, surgeons have infrequently participated in the curriculum of first and second years of medical school. Students are not exposed to surgical role models and to early introduction to the excitement of a career in surgery to the extent that they need to be. The skills of problem-solving, decision-making approaches to rapid treatment, and expertise in pathophysiology and anatomy, which are all characteristic of surgeons, need to be emphasized in all years of the medical school curriculum. The past decade has seen medical schools throughout the country adopt major curricular innovations requiring multidisciplinary teaching in small groups. Surgeons need to be more involved in this format of teaching because they are able to contribute relevance and excitement to education in the preclinical years. Surgical faculty members also need recognition and support for their efforts in residency education to facilitate development, implementation, and evaluation of innovative educational approaches. Also, such recognition and support is necessary for the much-needed changes in continuing education. Recommendations Academic departments should provide in the budget salary support for clerkship directors and residency program directors and compensation for time spent by faculty in educational activities. To enable this to happen, surgical faculty need to join with the department chair to allow practice revenues to be redistributed to those educational activities the faculty holds in high value. Indeed, departmental income from all sources should be examined for appropriate distribution to support educational and administrative activities. The RRC-S should stipulate and review institutional financial support for the teaching programs. Academic surgery departments should play an active role in educational, administrative, and curriculum development activities of the school. Surgical faculty should actively seek opportunities to teach and mentor medical students in the first and second years of medical school. The effectiveness of teaching and the provision of education should be improved by: Requiring all academic surgical chairs and division chiefs to acquire fundamental knowledge of education and demonstrate commitment to promote high standards of education within their departments or divisions; Establishing standards for qualifications and training of clerkship directors and residency program directors in both education and administration. The Division of Education of the ACS should take the lead in establishing and supporting these standards, working collaboratively with the Association of Program Directors in Surgery, the Association for Surgical Education, and the Residency Review Committees. Providing faculty development courses in teaching and the education process; Recruiting surgical faculty with advanced training in education and educational research; Requiring clerkship directors and residency program directors to participate in training in program development and evaluation before assuming responsibility for educational programs; and Making research in education a priority and providing the necessary resources to develop it (salary support, space, equipment, grants, and so on). Surgical faculty should take responsibility to promote to students the attractiveness of a career in surgery by: Providing opportunities to students to see the lifestyle and professional satisfaction of surgeons through social interactions; Developing surgical clubs, research opportunities, preceptorship, and mentorship; and Designing surgical clerkship and resident preparedness courses of the highest quality to meet leading-edge standards of teaching and evaluation. Surgery departments should develop surgical skills laboratories with an appropriate program of instructions and validated system of evaluations. The Division of Education of the ACS should play a leadership role in setting and monitoring the standards for skills centers nationally. Fund raising should be a strategic priority for academic surgery departments. External grants and support for endowed chairs should be sought from alumni, philanthropic donors, and corporations. Training in Surgical Research The research and innovation of American surgeons throughout the centuries has contributed significantly to scientific knowledge and has helped develop the best patient care in the world. A few examples that may be cited include the development of anesthesia, antisepsis, blood transfusion, organ transplantation, open heart surgery, clinical nutrition, joint replacement, biomaterial, and artificial organs. The future of surgery as an academic and professional discipline that will continue to contribute to the discovery and clinical translation of new knowledge, technology, and surgical therapeutic innovation might depend on how high research is on the priority scale of surgical education and practice. Great need and urgency exist to train clinical investigators and surgeon-scientists. It is inherent in the education of a surgeon that he or she be exposed to a thorough understanding of basic scientific methods. It is especially important that the surgeon in training understands the appropriate methods of evaluating published material, clinical research, and decision analysis. Research training in surgery is regarded almost as an afterthought, and the surgical profession has not placed a premium on its development and support. Research training in surgery lacks the structure, organization, and oversight that are so well developed for clinical training. No organization has assumed the responsibility to provide oversight for research training. The Committee views with concern the unstructured, obligatory 1 or 2 years of research required as a prerequisite to enter training in some specialty programs. The value of this research experience should be assessed based on its benefits to the individual and the specialty. Research proposals by surgeons are less likely to be funded by the National Institutes of Health (NIH). Few surgeons participate in the NIH review process, and surgeons are in the minority even within the Surgery Study Section. Although we continue to hold a strong perception that surgical research is not fairly reviewed and funded, we must also accept that research proposals from surgeons sometimes lack scientific rigor and originality. One factor that contributes to making surgeons less competitive in research funding is the lack of adequate protected time for research. Recommendations The Division of Research and Optimal Patient Care of the ACS should play a leadership role in coordinating with the ABS, with the RRC for Surgery and the Society of Surgical Chairs to develop a definitive agenda for the research training of surgeons. Such an agenda should include: Training of all residents in basic research methods and biostatistics during the residency; Creation of a surgeon-scientist training pathway leading to a Masters and/or PhD degree; Provision of opportunity for residents and fellows to avail themselves of advanced, curriculum-based training in clinical research, public health, or policy. Ideally, such training should lead to a degree. Identification of a single organization that should be responsible for setting standards, evaluation, and oversight. The academic surgical community should develop measures to enhance opportunities for a career in surgical research and to integrate research into clinical practice. Every effort must be made to take full advantage of the new NIH Roadmap that emphasizes clinical research and training coordination throughout the country. Leaders of surgery should engage in serious discussion with the NIH leadership to make the case for a robust surgical enterprise as a necessary asset to the health care of the nation. Such discussion should be preceded by assembling data, unassailable evidence of commitment by the surgical community to the scientific discipline, and developing a tightly reasoned argument why research in surgery is so important to the country. Continuous Professional Development The Blue Ribbon Committee of the ASA recognizes the importance of continuous professional development (CPD) in the acquisition and maintenance of surgical competence. The competencies of medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and systems-based practice should be addressed within the context of CPD using cutting-edge educational approaches and state-of-the-art technology. Principles of contemporary adult education, effective experiential learning, and development of expertise should form the basis of educational efforts directed at supporting CPD. These principles should also be considered within the context of Maintenance of Certification as efforts are made to address the commitment to lifelong learning and involvement in periodic self-assessment, assessment of cognitive expertise, and evaluation of performance in practice. The Blue Ribbon Committee discussed many of the general concepts underlying effective surgical education and interventions but made a conscious decision to only focus on the educational needs of surgical residents and medical students, and not to directly address issues relating to CPD. The Division of Education of the ACS is pursuing a spectrum of educational activities to support CPD and will continue to play a pivotal role in this regard, working collaboratively with Surgery Specialty Boards, accrediting bodies, and licensing authorities. Closing Remarks The work of the Blue Ribbon Committee was generously supported by the ASA, ACS, and ABS and effectively staffed by the Division of Education of the ACS. Special recognition needs to be given to Patrice Gabler Blair, MPH, Associate Director of the Division of Education, ACS, for playing a pivotal role in supporting the activities of the Blue Ribbon Committee. She was ably assisted by Rosemary Morrison, Administrative Assistant, Division of Education, ACS. As the Blue Ribbon Committee completes its work, it requests that its mission and goals be carried forward by the ACS, much as was done with past projects of national importance. The committee recommends that the ACS should establish mechanisms to address the recommendations of the committee, in collaboration with other national organizations such as the ABS, the RRC-S, and the Association of Program Directors in Surgery, the Association for Surgical Education, and the Association of American Medical Colleges. The ACS is also requested to provide the Council of the ASA annual reports outlining the status of the recommendations and the progress made in addressing various items. References Cooper RA. Weighing the evidence for expanding physician supply. Ann Intern Med. 2004;141:705-714. Acknowledgements Finally, the Committee wishes to express its thanks and profound appreciation to the American College of Surgeons, Division of Education, and in particular to Ms. Patrice Gabler Blair, MPH, Associate Director, and Ms. Rosemary Morrison, Administrative Assistant, who staffed the Committee's work for the entire 2 years with dedication, expertise, and great professionalism. Reprint Address Reprints: Haile T. Debas, MD, Chairman, ASA Blue Ribbon Committee on Surgical Education, Executive Director, UCSF Global Health Sciences, 3333 California St., Suite285, San Francisco, CA 94143-0443. E-mail: hdebas@globalhealth.ucsf.edu.