Ralph D. Cresman
The American Journal of Surgery 140
PRESIDENTIAL
ADDRESS
A Clinical Teacher Looks at Surgical Education Ralph D. Cressman, MD, Palo Alto, California
Twenty-five years ago I had the good fortune to become a member of this society. The Annual Meetings since then with their excellent scientific programs and the association and exchange of ideas with other members have been a source of education, enjoyment, and satisfaction which I must acknowledge. For this past year and during this current meeting it is my privilege to serve as your president and to address you this morning. For all this my humble thanks. Two or three years ago we were standing at the scrub sink outside the operating room getting ready to repair an inguinal hernia. A medical student serving a surgical clerkship was on the general surgical private teaching service with us at the time. He was going to scrub in on this case which he had worked up the night before. To begin, the discussion while we were scrubbing, I asked what type hernia he thought the patient had and he said he didn’t know. As to what type hernias there were, there was the same answer, so I inquired as to whether he had not yet had any lectures on hernia. This led to the disclosure that there were no formal lectures in surgery, no required formal didactic courses, but only elective clerkships taken at the student’s desire, in sufficient number and kind to pass the National Boards. With this incident in mind, I have been considering the matter of surgical education, both of undergraduate and future surgeons or nonsurgeons and postdoctoral programs in surgery, resulting in some thoughts which I would share with you this morning. You may agree or disagree in whole or in part with what I have to say. It appears that the student ferment of recent years has spread to the conservative citadel of the medical school. The demand of students to be granted a greater voice in their education, in the selection of the course of study, to get away from the “spoon feeding,
Reprint requests shouldbe addrd
to Ralph D. Ceasemen,MD. 300 Homer Avenue, Palo Alto, Callfomia 94301. Presented at the Forty-Seventh Annual Meeting of the Pacific Coest Surgical Association, Monterey, California, February 15-18, 1976.
Volume 132, Auguet 1976
rote learning, lock step system” of education has shifted the course away from the traditional uniform curriculum to a more permissive route. There has been a greater effort to introduce clinical material into the basic science studies of the first two or traditional preclinical years, followed in the next two years in many schools by elective clinical clerkships. The extent of choice and requirements in these varies from almost complete freedom to rather set limits. A survey by the American Medical Association of clinical clerkships in United States medical schools in 1975 reported that several specified the number of clerkships but the type was elective with the student. The average number of weeks spent in internal medicine is 11.5, in surgery 9, in pediatrics 7.5, in obstetrics-gynecology 6.5, in psychiatry 6, and in family medicine 5.5. Of 114 schools, a clerkship in internal medicine was required by 105, obstetricsgynecology 104, pediatrics 103, psychiatry 102, and surgery 107. In required clerkships then, surgery rates first in importance, but in several schools it is not required at all. Some of us, and I would think that most clinical surgeons would fall in this class, think there has been too much deemphasis of the necessity of surgical teaching in these clinical years, a downgrading of the importance of the patient’s history and physical examination, the bedside aspects of medicine, and too great a regard for the importance of the “explosion in scientific knowledge” as typified in the reliance on laboratory studies or other mechanical measurement approaches to the patient’s illness. The view has been expressed that surgery is a specialty to be learned in the postgraduate period if and when the student decides to enter this field, and that its teaching to those who will later be nonsurgeons is a waste of time and effort. Thus, no regular course of lectures or demonstrations, designed to cover even in a general way the field of general surgery, may be offered or required, and a course in the “dog lab” may be an unusual experience. It appears to me that what might be termed the basic or core knowledge of surgery is not only useful but necessary,
141
Cressman
regardless of later specialization. Latest figures indicate that about 60 per cent of medical school graduates entered advanced training in primary care specialties which the AMA defines as family practice, obstetrics-gynecology, pediatrics, or internal medicine. It would seem to follow that the doctor providing primary care should be familiar enough with surgery to render adequate treatment, if only in a referral manner to those with surgical conditions he sees in his role of primary care. An example that might be cited is that of the medical endoscopist who should have some surgical knowledge to appreciate the risks and complications, to recognize those complications when they occur, and to have some idea of treatment if he is to act intelligently. Another possible failure in the clinical clerkship system may be that in practice if not in principle there is a greater dependence on the intern or resident for teaching the student than on the more experienced teacher. In addition, the student may be exposed to a narrow or wide range of clinical material depending on the clerkship. Does it not follow that there is still a place in the curriculum for a survey or basic course in surgery, to cover the fields of wound healing, infection, surgical anatomy, and the common surgical problems, to properly prepare the student for his clerkship, or to supplement it? It also follows that this same conclusion applies to internal medicine or the other major disciplines in medicine. Is a dog surgery course of enough value that it should be offered to or required of all students, or offered to just those who are planning a surgical career, or to none at all? Here is a place to acquaint the student with some general if not comprehensive feeling for anesthesia, aseptic technic, tissue handling, and a bit of the mechanics of surgical technic that will prove of later value regardless of his final choice of specialty. No matter how restricted that specialty may be, a clinician in the real sense of the word must have a broad background of knowledge in medicine, using the word in the broadest sense. On July 1, the new trainees arrive to begin their postdoctoral program; formerly interns, now first year residents in name, but all with the desire to learn and most important to get to the all important business of operating, to “use the knife.” They are assigned to the emergency room under more or less supervision or on the ward and the operating room to work, to observe, and to learn to be surgeons. Many of you have read William Nolen’s book The Making of a Surgeon, in which he describes his training in a large city hospital. It will have recalled to all of you incidents, situations, and patterns which were common to most residency training programs. There is
142
the episode of the intern’s first appendectomy under the guidance of the resident. He has difficulty with knowing how to make an incision, is all thumbs in tying off the appendix stump, the tie comes off as the cecum falls back into the abdomen, with soiling of the ,peritoneum, a stormy course for the patient results, with a worrisome time for the intern and a harrowing experience for the resident. Does it sound familiar? Is it still done that way today? If it is, should it? There is a better way. It has been pointed out to us, for example, by the workshops in microsurgery or the courses in the use of the stapler in surgery. In short, the technics of surgery should be taught in the laboratory and should start with the fundamentals of how to use one’s hands with those unaccustomed tools-knife, scissors, needle, and thread-upon unaccustomed material such as human tissue. Before performing an agonizingly slow, clumsy closure of a laceration in the emergency room or before the first fumbling attempts in the operating room, the new intern-resident should complete a laboratory course using synthetic materials, animal tissues, and anesthetized animals. In a period of two to four weeks, concentrating only on this course, moderate hand dexterity and proficiency in the use of surgical instruments could be learned so that the trainee would be ready to concentrate on diagnosis and treatment. Such a course would take time, facilities, and money but should save in the long run, if one considers the possible cost of clinical technical errors. The facilities should be available in most desirable training centers, the great majority of which are a part of or affiliated with university teaching programs. The SOSSUS study suggests that there are more than enough surgical residencies to provide the number of surgeons required in the United States. Programs which do not have the necessary facilities would no doubt be the first to be eliminated. Another conclusion from the SOSSUS study concerns the high failure rate in examinations for Board Certification in certain categories. It should follow that training programs in which there are high failure rates are probably inadequate and should be curtailed. The era of the big city or county hospital and the free clinic as the major center for residency training is phasing out with the newer social programs of Medicaid and Medicare. It has become necessary to arrange teaching programs in which private patients play a large role, but private practitioners and parttime clinical faculty will be reluctant to have their patients in teaching programs unless certain condi-: tions can be met. The care of the patient must be as expeditious, the surgical risks no greater, the overall
The Amrkan
Journal d Surgery
Presidential Address
care as good or better and not more expensive on the teaching program than in a nonteaching situation. This can be done and is being done, but it requires cooperation between the teaching institution and the part-time faculty. Control of the patient must stay with his private doctor, who on the other hand must be interested in teaching. Instruction cannot be left to the man one‘step above on the ladder-the student by the intern, the intern by the first year resident, and so on up-or to the “see one, do one, teach one” method described by Nolen in his training. The trainee learns by seeing many patients, by his reading, and by the counsel of his teachers. Thus, he perfects his diagnostic ability and learns when or when not to operate, what operation to do, and the fundamentals of pre- and postoperative care. But our senior teachers, our professors, must be available. They are of no help to the resident staff when in Washington, DC or visiting a foreign country. Our own Doctor J. Englebert Dunphy said in a Harvard Medical Alumni Day address in 1968: “The real troubles with medical education are four in number: first, the preclinical scientist is being taken away from the student; second, the strict fulltime system is taking the clinical faculty away from the patient; third, the pressures of administration are taking the heads of departments away from the students, patients, and laboratories; finally, jet travel is taking everybody away from everybody else.” There are no substitutes for the gems of clinical acumen which can be imparted by the wise and experienced teacher. Who among you does not have a picture or pictures of revered teachers on his office
volume 132, Au@ud 1976
wall, to whom he acknowledges his debt for his training? In my office is the picture of Glenn Bell, past president of this Association, that superb surgical technician and teacher of the Halsted system of surgery, yet to all of his residents an example of warm doctor/patient relationship, full of sympathy and understanding. And there is the picture of Howard Nafzigger, also past president of this Association, brilliant neurosurgeon, yet Chairman of the Department of Surgery, who presided at General Surgery Grand Rounds every week, participating in and directing the discussion. Those who followed him on his rounds were priviledged to learn the niceties of a neurologic examination and were also aware of his demanding standard of excellence in the work of students or house staff. Such examples are familiar in each of your experiences and are cited to emphasize the importance of clinical teaching. It is not necessary to have a lock step system, but too far a swing to a nonsystem is worse. We have methods available to improve postdoctoral training in the technical phase of surgery which should be implemented. The use of private patients in the training programs is possible and desirable under the proper guidelines. Good students will do well in spite of any system, but the road should not purposefully be made more difficult. Much has been made of the view that what we accept as fact today may in large part be proved false in our lifetime, that instead of facts, students must be taught in reasoning and problem solving. But problem solving requires a point of departure, a body of facts as we know them at the time, and this is what we must also provide.
143
The American Journal of Surgery 140
PRESIDENTIAL
ADDRESS
A Clinical Teacher Looks at Surgical Education Ralph D. Cressman, MD, Palo Alto, California
Twenty-five years ago I had the good fortune to become a member of this society. The Annual Meetings since then with their excellent scientific programs and the association and exchange of ideas with other members have been a source of education, enjoyment, and satisfaction which I must acknowledge. For this past year and during this current meeting it is my privilege to serve as your president and to address you this morning. For all this my humble thanks. Two or three years ago we were standing at the scrub sink outside the operating room getting ready to repair an inguinal hernia. A medical student serving a surgical clerkship was on the general surgical private teaching service with us at the time. He was going to scrub in on this case which he had worked up the night before. To begin, the discussion while we were scrubbing, I asked what type hernia he thought the patient had and he said he didn’t know. As to what type hernias there were, there was the same answer, so I inquired as to whether he had not yet had any lectures on hernia. This led to the disclosure that there were no formal lectures in surgery, no required formal didactic courses, but only elective clerkships taken at the student’s desire, in sufficient number and kind to pass the National Boards. With this incident in mind, I have been considering the matter of surgical education, both of undergraduate and future surgeons or nonsurgeons and postdoctoral programs in surgery, resulting in some thoughts which I would share with you this morning. You may agree or disagree in whole or in part with what I have to say. It appears that the student ferment of recent years has spread to the conservative citadel of the medical school. The demand of students to be granted a greater voice in their education, in the selection of the course of study, to get away from the “spoon feeding,
Reprint requests shouldbe addrd
to Ralph D. Ceasemen,MD. 300 Homer Avenue, Palo Alto, Callfomia 94301. Presented at the Forty-Seventh Annual Meeting of the Pacific Coest Surgical Association, Monterey, California, February 15-18, 1976.
Volume 132, Auguet 1976
rote learning, lock step system” of education has shifted the course away from the traditional uniform curriculum to a more permissive route. There has been a greater effort to introduce clinical material into the basic science studies of the first two or traditional preclinical years, followed in the next two years in many schools by elective clinical clerkships. The extent of choice and requirements in these varies from almost complete freedom to rather set limits. A survey by the American Medical Association of clinical clerkships in United States medical schools in 1975 reported that several specified the number of clerkships but the type was elective with the student. The average number of weeks spent in internal medicine is 11.5, in surgery 9, in pediatrics 7.5, in obstetrics-gynecology 6.5, in psychiatry 6, and in family medicine 5.5. Of 114 schools, a clerkship in internal medicine was required by 105, obstetricsgynecology 104, pediatrics 103, psychiatry 102, and surgery 107. In required clerkships then, surgery rates first in importance, but in several schools it is not required at all. Some of us, and I would think that most clinical surgeons would fall in this class, think there has been too much deemphasis of the necessity of surgical teaching in these clinical years, a downgrading of the importance of the patient’s history and physical examination, the bedside aspects of medicine, and too great a regard for the importance of the “explosion in scientific knowledge” as typified in the reliance on laboratory studies or other mechanical measurement approaches to the patient’s illness. The view has been expressed that surgery is a specialty to be learned in the postgraduate period if and when the student decides to enter this field, and that its teaching to those who will later be nonsurgeons is a waste of time and effort. Thus, no regular course of lectures or demonstrations, designed to cover even in a general way the field of general surgery, may be offered or required, and a course in the “dog lab” may be an unusual experience. It appears to me that what might be termed the basic or core knowledge of surgery is not only useful but necessary,
141
Cressman
regardless of later specialization. Latest figures indicate that about 60 per cent of medical school graduates entered advanced training in primary care specialties which the AMA defines as family practice, obstetrics-gynecology, pediatrics, or internal medicine. It would seem to follow that the doctor providing primary care should be familiar enough with surgery to render adequate treatment, if only in a referral manner to those with surgical conditions he sees in his role of primary care. An example that might be cited is that of the medical endoscopist who should have some surgical knowledge to appreciate the risks and complications, to recognize those complications when they occur, and to have some idea of treatment if he is to act intelligently. Another possible failure in the clinical clerkship system may be that in practice if not in principle there is a greater dependence on the intern or resident for teaching the student than on the more experienced teacher. In addition, the student may be exposed to a narrow or wide range of clinical material depending on the clerkship. Does it not follow that there is still a place in the curriculum for a survey or basic course in surgery, to cover the fields of wound healing, infection, surgical anatomy, and the common surgical problems, to properly prepare the student for his clerkship, or to supplement it? It also follows that this same conclusion applies to internal medicine or the other major disciplines in medicine. Is a dog surgery course of enough value that it should be offered to or required of all students, or offered to just those who are planning a surgical career, or to none at all? Here is a place to acquaint the student with some general if not comprehensive feeling for anesthesia, aseptic technic, tissue handling, and a bit of the mechanics of surgical technic that will prove of later value regardless of his final choice of specialty. No matter how restricted that specialty may be, a clinician in the real sense of the word must have a broad background of knowledge in medicine, using the word in the broadest sense. On July 1, the new trainees arrive to begin their postdoctoral program; formerly interns, now first year residents in name, but all with the desire to learn and most important to get to the all important business of operating, to “use the knife.” They are assigned to the emergency room under more or less supervision or on the ward and the operating room to work, to observe, and to learn to be surgeons. Many of you have read William Nolen’s book The Making of a Surgeon, in which he describes his training in a large city hospital. It will have recalled to all of you incidents, situations, and patterns which were common to most residency training programs. There is
142
the episode of the intern’s first appendectomy under the guidance of the resident. He has difficulty with knowing how to make an incision, is all thumbs in tying off the appendix stump, the tie comes off as the cecum falls back into the abdomen, with soiling of the ,peritoneum, a stormy course for the patient results, with a worrisome time for the intern and a harrowing experience for the resident. Does it sound familiar? Is it still done that way today? If it is, should it? There is a better way. It has been pointed out to us, for example, by the workshops in microsurgery or the courses in the use of the stapler in surgery. In short, the technics of surgery should be taught in the laboratory and should start with the fundamentals of how to use one’s hands with those unaccustomed tools-knife, scissors, needle, and thread-upon unaccustomed material such as human tissue. Before performing an agonizingly slow, clumsy closure of a laceration in the emergency room or before the first fumbling attempts in the operating room, the new intern-resident should complete a laboratory course using synthetic materials, animal tissues, and anesthetized animals. In a period of two to four weeks, concentrating only on this course, moderate hand dexterity and proficiency in the use of surgical instruments could be learned so that the trainee would be ready to concentrate on diagnosis and treatment. Such a course would take time, facilities, and money but should save in the long run, if one considers the possible cost of clinical technical errors. The facilities should be available in most desirable training centers, the great majority of which are a part of or affiliated with university teaching programs. The SOSSUS study suggests that there are more than enough surgical residencies to provide the number of surgeons required in the United States. Programs which do not have the necessary facilities would no doubt be the first to be eliminated. Another conclusion from the SOSSUS study concerns the high failure rate in examinations for Board Certification in certain categories. It should follow that training programs in which there are high failure rates are probably inadequate and should be curtailed. The era of the big city or county hospital and the free clinic as the major center for residency training is phasing out with the newer social programs of Medicaid and Medicare. It has become necessary to arrange teaching programs in which private patients play a large role, but private practitioners and parttime clinical faculty will be reluctant to have their patients in teaching programs unless certain condi-: tions can be met. The care of the patient must be as expeditious, the surgical risks no greater, the overall
The Amrkan
Journal d Surgery
Presidential Address
care as good or better and not more expensive on the teaching program than in a nonteaching situation. This can be done and is being done, but it requires cooperation between the teaching institution and the part-time faculty. Control of the patient must stay with his private doctor, who on the other hand must be interested in teaching. Instruction cannot be left to the man one‘step above on the ladder-the student by the intern, the intern by the first year resident, and so on up-or to the “see one, do one, teach one” method described by Nolen in his training. The trainee learns by seeing many patients, by his reading, and by the counsel of his teachers. Thus, he perfects his diagnostic ability and learns when or when not to operate, what operation to do, and the fundamentals of pre- and postoperative care. But our senior teachers, our professors, must be available. They are of no help to the resident staff when in Washington, DC or visiting a foreign country. Our own Doctor J. Englebert Dunphy said in a Harvard Medical Alumni Day address in 1968: “The real troubles with medical education are four in number: first, the preclinical scientist is being taken away from the student; second, the strict fulltime system is taking the clinical faculty away from the patient; third, the pressures of administration are taking the heads of departments away from the students, patients, and laboratories; finally, jet travel is taking everybody away from everybody else.” There are no substitutes for the gems of clinical acumen which can be imparted by the wise and experienced teacher. Who among you does not have a picture or pictures of revered teachers on his office
volume 132, Au@ud 1976
wall, to whom he acknowledges his debt for his training? In my office is the picture of Glenn Bell, past president of this Association, that superb surgical technician and teacher of the Halsted system of surgery, yet to all of his residents an example of warm doctor/patient relationship, full of sympathy and understanding. And there is the picture of Howard Nafzigger, also past president of this Association, brilliant neurosurgeon, yet Chairman of the Department of Surgery, who presided at General Surgery Grand Rounds every week, participating in and directing the discussion. Those who followed him on his rounds were priviledged to learn the niceties of a neurologic examination and were also aware of his demanding standard of excellence in the work of students or house staff. Such examples are familiar in each of your experiences and are cited to emphasize the importance of clinical teaching. It is not necessary to have a lock step system, but too far a swing to a nonsystem is worse. We have methods available to improve postdoctoral training in the technical phase of surgery which should be implemented. The use of private patients in the training programs is possible and desirable under the proper guidelines. Good students will do well in spite of any system, but the road should not purposefully be made more difficult. Much has been made of the view that what we accept as fact today may in large part be proved false in our lifetime, that instead of facts, students must be taught in reasoning and problem solving. But problem solving requires a point of departure, a body of facts as we know them at the time, and this is what we must also provide.
143
