References 1. Berlauk JF, Abrahams JH, Gilmour IJ, et al. Preoperative optimization of cardiovascular hemodynamics improves outcome in peripheral vascular surgery. A prospective, randomized trial. Ann Surg 1991; 214:289-299.
JEFFREY S. BENDER, M.D. Baltimore, MD December 16, 1991 Dear Editor:
Dr. Bender's questions provide an opportunity to present some data not included in our original paper (Table 1). TABLE 1. Perioperative Fluids
Anesthesia time (hr) Blood loss (mL) Total crystalloid* (mL) Total colloid* (mL) Blood* (mL)
103
LETTERS TO THE EDITOR
Vol. 216 * No. I
Group I
Group 2
Group 3
(n =43)
(n =23)
(n
5.8 ± 1.2 328 246 2756 ± 1426 875 ± 528 162 295
5.3 + 1.3 311 186 2418 ± 1080 812 ± 423 174 305
=
21)
5.1 ± 310 ± 2636 ± 352 ± 83 ±
1.3 163 897 398 213
Mean ± SD. * IV fluid administered from entrance into study through surgery.
All patients in the study received an in situ vein graft bypass of a peripheral lower extremity arterial occlusion. No other procedures were included. There were no statistically significant differences between groups in anesthesia time, intraoperative blood loss, or perioperative fluids administered. After inclusion into the study, all patients were treated equally except for patient care issues related to the cardiovascular tuneup. In the study group, this included pulmonary artery catheter monitoring, and infusions of dopamine, dobutamine, nitroglycerin, and nitroprusside as well as the precordial nitropaste. We do not believe our results were dependent on a single variable, but instead reflect an integrated team approach to optimizing cardiovascular function in the high-risk patient. To answer Dr. Bender's question specifically, precordial nitropaste was not given to control patients, and neither study nor control patients routinely received postoperative anticoagulation. About 35% of patients received continuous intravenous heparin infusion if clinically indicated. There were no statistically significant differences
Professions, for all their cloaking of specialized knowledge, codes ofethics, and societal prominence, all began as little more than skilled trades. It is humbling to realize that most of the reasons for the professional ethics and arduous training regimens characteristic of professions were created with a purely economic motive in mind-by restricting the entrance into the profession, and ensuring the quality ofthe product produced, those members already established in the profession (those who made the rules) could have their income guaranteed. Because professions consistently delivered a product important to society, they have been largely allowed to regulate themselves. It is only recently, as society has become more educated, that certain operations of the professions have been questioned. It is not surprising that suggestions and attempts to alter the admission criteria for medical specialties should offend some practitioners. The suggestion that residencies should be made "easier" is tantamount to easing an important entrance requirement for surgery to allow more people to enter the field. It may be this concern, in part, that fueled the resentment evident in the editorial. It is possibly instructive to examine arguments that could support changing residencies while maintaining important aspects of professionalism necessary to medical practice. A residency cannot, despite its number of hours, expose a physician in training to all of the range of cases he or she will experience in practice, nor will performing a set number of procedures guarantee that a surgeon will be able to adapt to new procedures when old ones are superseded by changing technology and research. What professional education should do is provide an environment wherein a young professional is exposed to enough variety, and enough stress, that he or she may learn and practice enough basic skills to be able to learn new ones or adapt the old to a novel situation. The other important requirement is demonstrating to the young professional the importance of learning how to learn-being able to adapt to the constantly changing and expanding knowledge base ofthe profession as a whole. Part of this adaptation may be learning to recognize that things are not always right because that was the way they always have been done-there may be a more effective way of doing something that requires a change on the part of the profession. References 1. Wilson FC. On work hours for residents. Ann Surg 1991; 214:553554.
SPENCER A. HALL, M.D., J.D. Lincoln, New Mexico
between groups. JON F. BERLAUK, M.D.
March 18, 1992
Minneapolis, Minnesota Dear Editor:
December 13, 1991 Dear Editor: A recent editorial' expressed resentment at the idea of restrictions suggested, or enacted, for residency training programs and implied that professions are different than trades. A review of what a profession is and what it should be should place that point of view in context.
In his initial paragraph, Dr. Hall refers to my "resentment" of nationally imposed work hour limits for resident physicians. What I intended to express was disagreement with the proposal, that is, a reasoned rather than an emotional response. He appears, from subsequent comments, to believe that opposition to such proposals is motivated by economic concerns, implying that professions were created for "purely economic" motives, so that members of the profession "could have their income guaranteed." Professionals do have higher income expectations; how-
JEFFREY S. BENDER, M.D. Baltimore, MD December 16, 1991 Dear Editor:
Dr. Bender's questions provide an opportunity to present some data not included in our original paper (Table 1). TABLE 1. Perioperative Fluids
Anesthesia time (hr) Blood loss (mL) Total crystalloid* (mL) Total colloid* (mL) Blood* (mL)
103
LETTERS TO THE EDITOR
Vol. 216 * No. I
Group I
Group 2
Group 3
(n =43)
(n =23)
(n
5.8 ± 1.2 328 246 2756 ± 1426 875 ± 528 162 295
5.3 + 1.3 311 186 2418 ± 1080 812 ± 423 174 305
=
21)
5.1 ± 310 ± 2636 ± 352 ± 83 ±
1.3 163 897 398 213
Mean ± SD. * IV fluid administered from entrance into study through surgery.
All patients in the study received an in situ vein graft bypass of a peripheral lower extremity arterial occlusion. No other procedures were included. There were no statistically significant differences between groups in anesthesia time, intraoperative blood loss, or perioperative fluids administered. After inclusion into the study, all patients were treated equally except for patient care issues related to the cardiovascular tuneup. In the study group, this included pulmonary artery catheter monitoring, and infusions of dopamine, dobutamine, nitroglycerin, and nitroprusside as well as the precordial nitropaste. We do not believe our results were dependent on a single variable, but instead reflect an integrated team approach to optimizing cardiovascular function in the high-risk patient. To answer Dr. Bender's question specifically, precordial nitropaste was not given to control patients, and neither study nor control patients routinely received postoperative anticoagulation. About 35% of patients received continuous intravenous heparin infusion if clinically indicated. There were no statistically significant differences
Professions, for all their cloaking of specialized knowledge, codes ofethics, and societal prominence, all began as little more than skilled trades. It is humbling to realize that most of the reasons for the professional ethics and arduous training regimens characteristic of professions were created with a purely economic motive in mind-by restricting the entrance into the profession, and ensuring the quality ofthe product produced, those members already established in the profession (those who made the rules) could have their income guaranteed. Because professions consistently delivered a product important to society, they have been largely allowed to regulate themselves. It is only recently, as society has become more educated, that certain operations of the professions have been questioned. It is not surprising that suggestions and attempts to alter the admission criteria for medical specialties should offend some practitioners. The suggestion that residencies should be made "easier" is tantamount to easing an important entrance requirement for surgery to allow more people to enter the field. It may be this concern, in part, that fueled the resentment evident in the editorial. It is possibly instructive to examine arguments that could support changing residencies while maintaining important aspects of professionalism necessary to medical practice. A residency cannot, despite its number of hours, expose a physician in training to all of the range of cases he or she will experience in practice, nor will performing a set number of procedures guarantee that a surgeon will be able to adapt to new procedures when old ones are superseded by changing technology and research. What professional education should do is provide an environment wherein a young professional is exposed to enough variety, and enough stress, that he or she may learn and practice enough basic skills to be able to learn new ones or adapt the old to a novel situation. The other important requirement is demonstrating to the young professional the importance of learning how to learn-being able to adapt to the constantly changing and expanding knowledge base ofthe profession as a whole. Part of this adaptation may be learning to recognize that things are not always right because that was the way they always have been done-there may be a more effective way of doing something that requires a change on the part of the profession. References 1. Wilson FC. On work hours for residents. Ann Surg 1991; 214:553554.
SPENCER A. HALL, M.D., J.D. Lincoln, New Mexico
between groups. JON F. BERLAUK, M.D.
March 18, 1992
Minneapolis, Minnesota Dear Editor:
December 13, 1991 Dear Editor: A recent editorial' expressed resentment at the idea of restrictions suggested, or enacted, for residency training programs and implied that professions are different than trades. A review of what a profession is and what it should be should place that point of view in context.
In his initial paragraph, Dr. Hall refers to my "resentment" of nationally imposed work hour limits for resident physicians. What I intended to express was disagreement with the proposal, that is, a reasoned rather than an emotional response. He appears, from subsequent comments, to believe that opposition to such proposals is motivated by economic concerns, implying that professions were created for "purely economic" motives, so that members of the profession "could have their income guaranteed." Professionals do have higher income expectations; how-
