Professionalism

Medical professionalism has been increasingly discussed over the last decade. Its importance in surgical education is also being recognized, both at undergraduate and postgraduate level, but difficulty in definition has meant it is hard to assess. Justice Potter Stuart said of pornography ‘I know what it is when I see it’, and professionalism is defined by many in the same way. It is, however, the central core of our work as doctors, inherent in our interactions with patients, colleagues and paramedical staff. It is the behaviour by which we are judged. This article will set professionalism in context in modern surgical education, and will examine available methods to teach, predict and measure it. The professional duties of both individuals and organizations will be examined and the impact of the digital revolution explored.     

The professionalism curriculum as a cultural change agent in surgical residency education

BackgroundTeaching professionalism effectively to fully engaged residents is a significant challenge. A key question is whether the integration of professionalism into residency education leads to a change in resident culture.MethodsThe goal of this study was to assess whether professionalism has taken root in the surgical resident culture 3 years after implementing our professionalism curriculum. Evidence was derived from 3 studies: (1) annual self-assessments of the residents' perceived professionalism abilities to perform 20 defined tasks representing core Accrediting Council on Graduate Medical Education professionalism domains, (2) objective metrics of their demonstrated professionalism skills as rated by standardized patients annually using the objective structure clinical examination tool, and (3) a national survey of the Surgical Professionalism and Interpersonal Communications Education Study Group.ResultsStudy 1: aggregate perceived professionalism among surgical residents shows a statistically significant positive trend over time (P = .016). Improvements were seen in all 6 domains: accountability, ethics, altruism, excellence, patient sensitivity, and respect. Study 2: the cohort of residents followed up over 3 years showed a marked improvement in their professionalism skills as rated by standardized patients using the objective structure clinical examination tool. Study 3: 41 members of the national Surgical Professionalism and Interpersonal Communications Education Study Group rated their residents' skills in admitting mistakes, delivering bad news, communication, interdisciplinary respect, cultural competence, and handling stress. Twenty-nine of the 41 responses rated their residents as “slightly better” or “much better” compared with 5 years ago (P = .001). Thirty-four of the 41 programs characterized their department's leadership view toward professionalism as “much better” compared with 5 years ago.ConclusionsAll 3 assessment methods suggest that residents feel increasingly prepared to effectively deal with the professionalism challenges they face. Although professionalism seminars may have seemed like an oddity several years ago, residents today recognize their importance and value their professionalism skills. As importantly, department chairpersons report that formal professionalism education for residents is viewed more favorably compared with 5 years ago.     

Narrative medicine in surgical education

PURPOSE: Narrative medicine is a patient-centered approach to the practice of medicine that rescues the patients' stories and integrates what is important to them into decisions regarding their health care. Our hypothesis is that narrative understanding enhances the patient-provider relationship and contributes to optimizing patient care. We propose to use written narrative reflection to capture and measure the general competencies of systems-based practice, practice-based learning, communication skills, and professionalism. DEVELOPMENT/METHODS: The development of this narrative-based project is based on a pilot study that we conducted at our institution with third-year surgical clerkship students. In the pilot, students produced in-depth narrative write-ups on a patient they had had the opportunity to "know." We plan a similar approach for surgical resident education. After a brief discussion of narrative medicine during our scheduled didactic conference, the residents are asked to initiate a written narrative reflection on a patient of their choosing. The narratives will be collected 1 week later. Our plan is to repeat this assessment quarterly so that 4 narratives will be generated annually from internship through the chief resident year. EVALUATION: The narratives will be analyzed for content and recurring themes that capture the resident's communication skills, professionalism, as well as self-critique (practice-based learning) and value attributed to health-care teams (systems-based practice). OUTCOME MEASURES: After completion of the narratives, a 5-point Likert response survey will be given to the residents to assess their experience and the perceived value of written reflection. The written narratives will become part of the resident's ongoing portfolio. IMPLEMENTATION/EXPERIENCE TO DATE: Feedback from the medical student pilot study was favorable. When asked in a follow-up questionnaire, most students reported the experience to be valuable and recommended the use of narrative reflection in medical education. To assess the feasibility of this approach in surgical residency, we introduced the concept of narrative reflection to our residents during surgery grand rounds. Thirty-three narratives were collected 1 week later. CONCLUSION/NEXT STEPS: This preliminary experience suggests that acquisition of resident-authored narrative reflection is feasible during surgical residency. Use of this narrative-based approach in surgical resident education has the potential to capture and measure the general competencies of systems-based practice, practice-based learning, communication skills, and professionalism.     

Get on your boots: Preparing fourth-year medical students for a career in surgery, using a focused curriculum to teach the competency of professionalism

IntroductionFew educational programs exist for medical students that address professionalism in surgery, even though this core competency is required for graduate medical education and maintenance of board certification. Lapses in professional behavior occur commonly in surgical disciplines, with a negative effect on the operative team and patient care. Therefore, education regarding professionalism should begin early in the surgeon's formative process, to improve behavior. The goal of this project was to enhance the attitudes and knowledge of medical students regarding professionalism, to help them understand the role of professionalism in a surgical practice.MethodsWe implemented a 4-h seminar, spread out as 1-h sessions over the course of their month-long rotation, for 4th-year medical students serving as acting interns (AIs) in General Surgery, a surgical subspecialty, Obstetrics/Gynecology, or Anesthesia. Teaching methods included lecture, small group discussion, case studies, and journal club. Topics included Cognitive/Ethical Basis of Professionalism, Behavioral/Social Components of Professionalism, Managing Yourself, and Leading While You Work. We assessed attitudes about professionalism with a pre-course survey and tracked effect on learning and behavior with a post-course questionnaire. We asked AIs to rate the egregiousness of 30 scenarios involving potential lapses in professionalism.ResultsA total of 104 AIs (mean age, 26.5 y; male to female ratio, 1.6:1) participated in our course on professionalism in surgery. Up to 17.8% of the AIs had an alternate career before coming to medical school. Distribution of intended careers was: General Surgery, 27.4%; surgical subspecialties, 46.6%; Obstetrics/Gynecology, 13.7%; and Anesthesia, 12.3%. Acting interns ranked professionalism as the third most important of the six core competencies, after clinical skills and medical knowledge, but only slightly ahead of communication. Most AIs believed that professionalism could be taught and learned, and that the largest obstacle was not enough time in the curriculum. The most effective reported teaching methods were mentoring and modeling; lecture and journal club were the effective. Regarding attitudes toward professionalism, the most egregious examples of misconduct were substance abuse, illegal billing, boundary issues, sexual harassment, and lying about patient data, whereas the least egregious examples were receiving textbooks or honoraria from drug companies, advertising, self-prescribing for family members, and exceeding work-hour restrictions. The most important attributes of the professional were integrity and honesty, whereas the least valued were autonomy and altruism. The AIs reported that the course significantly improved their ability to define professionalism, identify attributes of the professional, understand the importance of professionalism, and integrate these concepts into practice (all P < 0.01).ConclusionsAlthough medical students interested in surgery may already have well-formed attitudes and sophisticated knowledge about professionalism, this core competency can still be taught to and learned by trainees pursuing a surgical career.     

The importance of international consensus statements in surgery*

The article is a summary of some of the pertinent literature on professionalism, highlighting the difference between how physicians understand professionalism and how other groups e.g. politicians, nurses and hospital managers might view the professionalism of doctors. It partly explains why surgeons have become increasingly ‘managerialised’ and lost autonomy since the 1970s. I speculate what might be the logical conclusion of this process if surgeons continue to be seen as technicians. The choice facing the surgical profession appears to be between retrenching, by this is meant resisting the challenges to traditional notions of professionalism, or reforming, i.e. to develop new workable models that better serve society and the profession. Some of this might make uncomfortable reading for physicians and surgeons; it is meant to.     

What does leadership in surgery entail?

Background: Leadership is not formally taught at any level in surgical training; there are no mandatory leadership courses or qualifications for trainees or specialists, and leadership performance is rarely evaluated within surgical appraisal or assessment programmes. Methods: Literature obtained from a MEDLINE search was reviewed to determine the characteristics of surgical leaders; outline an analytical framework through which these characteristics can be developed both in surgeons and surgical departments; and reflect on future challenges and recommendations for the central role of leadership in the field of surgery. Results: Leadership in surgery entails professionalism, technical competence, motivation, innovation, teamwork, communication skills, decision‐making, business acumen, emotional competence, resilience and effective teaching. Leadership skills can be developed through experience, observation, and education using a framework including mentoring, coaching, networking, stretch assignments, action learning and feedback. Conclusion: Modern surgery will need leaders with superior leadership skills that are well defined. It is vital that leadership programmes to develop leadership skills are put into practice in medical education curriculum and postgraduate surgical training. This will ensure maintenance and improvement in the quality of patient care.     

Teaching professionalism in orthopaedic residency

Two residents, wearing white coats with their names and "Department of Orthopaedics" conspicuously embroidered on them, boarded a hospital elevator crowded with physicians, employees, and visitors. In a clearly audible voice, one resident began a story: "You should have seen the patient I saw in my clinic the other day. She was beautiful. I should send her to see Dr. W. He would love to see her!" This comment drew the undivided attention of everyone in the elevator and cast a ghastly silence over the rest of the ride. In recent years, interest has expanded regarding professionalism and its importance in medicine and surgery. Orthopaedic surgery is no exception, as the topic has recently reached prominence in our literature and policies. It is unlikely that professionalism is a universal and innate characteristic of college students entering medical school, yet it becomes a necessary value in medical practice. Somewhere in the ongoing process of medical education, the issue must be addressed.     

The impact of COVID-19 on the future of orthopaedic training in the UK

The COVID-19 pandemic has had a major impact on global healthcare systems, has drastically affected patient care, and has had widespread effects upon medical education. As plans are being devised to reinstate elective surgical services, it is important to consider the impact that the pandemic has had and will continue to have on surgical training. We describe the effect COVID-19 has had at all levels of training in the UK within trauma and orthopaedics and evaluate how training might change in the future. We found that the COVID-19 pandemic has significantly impacted trainees within trauma and orthopaedics at all levels of training. It had led to reduced operative exposure, cancellations of examinations and courses, and modifications to speciality recruitment and annual appraisals. This cohort of trainees is witnessing novel methods of delivering orthopaedic services, which will continue to develop and become part of routine practice even once the pandemic has resolved. It will be important to observe the extent to which the rapid changes currently being introduced will impact the personal health, safety, and career progression of current trainees.

The COVID-19 pandemic has had a major impact on global healthcare systems, has drastically affected patient care, and has had widespread effects upon medical education. On the 23rd of March 2020, the UK government imposed a lockdown and introduced stringent social distancing measures in response to the rising number of COVID-19 infections. In the field of trauma and orthopaedics (T&O), COVID-19 led to an immediate restructuring of services, redeployment of doctors, and cancellation of elective operating.As plans are being devised to reinstate elective surgical services in the UK, it is important to consider the impact that the pandemic will have upon surgical training. This article describes the effect COVID-19 has had at all levels of training in the UK within T&O and evaluates how training might change in the future.     

A changing culture in interpersonal and communication skills

In summary it is essential that we improve our interpersonal and communication skills. We can learn and be taught better skills. We will be evaluated on these skills in the future, and it is important for us to establish ourselves as good role models for the future surgeons who will be entering our profession. It is of benefit to our patients and will give them a better understanding of their disease and elevate their level of healthcare. It is also important to us to help reduce our stress and to eliminate burnout. We can improve our interpersonal and communication skills in many ways. First we must be aware that there is a problem and recognize this as a problem that can be solved and that we do need to improve our current skills. This can be done through multiple educational tools such as lectures, videos, and self-assessments. The responsibility for this culture change ranges from top to bottom, but really begins at the bottom. It is important for all of us especially individuals such as myself, who is not only a practicing surgeon but also a surgeon in a leadership position, a surgeon who teaches medical students and residents, and a chairman who develops the careers of young faculty members. It is important for organizations such as the Southeastern Surgical Congress to recognize this need of our members and to conduct seminars, luncheons, and courses in helping us acquire better skills and also giving us some assessment of the current status of our skills. The American College of Surgeons has already addressed this issue by forming the Task Force on Communication and Educational Skills. Various examining boards have already incorporated this into requirements and expectations of future physicians and surgeons. We must establish ourselves as good role models. Being a good role model cannot be overemphasized. We are very fortunate in being good role models in medical knowledge and mastering phenomenal technical feats; however, this is not enough. It is also important that we also improve our interpersonal and communication skills. We must establish goals and outcomes for ourselves and work on ways of assessing these to ensure that we are effective in improving our skills. We must incorporate interpersonal and communication skills into our training programs, postgraduate courses, and all aspects of lifelong continuing education. Addressing the improvement of our interpersonal and communication skills will have many beneficial effects including improved patient outcomes, a better healthcare status for our patients, and a high level of confidence that patients have in us as physicians and surgeons. We do at times have a less than ideal collegial relationship with other disciplines in medicine. This faulty relationship needs to be rectified. We need to restore and maintain a high collegial relationship with everyone in medicine not only other physicians, but also nurses, paramedical personnel, and others. These changes will require a great deal of effort and will take some considerable time. Initially laparoscopic cholecystectomy and laparoscopic skills were not adequately learned but with recognition of its importance, education, and time, we became master surgeons. We are very fortunate to have residents and practitioners with superb laparoscopic skills that they acquired during their training and in structured postgraduate courses. Likewise it is important to incorporate interpersonal and communication skills into our training programs and our continuing medical educational programs. Finally, this is not just a touchy-feely issue, but it is one of surgical professionalism. It is critical for us to address this as an important issue since it will enhance the good qualities that we already possess. Let's start today. I have enjoyed this year being your President, and wish to thank you for the opportunity of addressing you this morning.     

Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic

We performed a narrative review to explore the economics of daily operating room management decisions for ambulatory surgery centers following resolution of the acute phase of the Coronavirus Disease 2019 (COVID-19) pandemic. It is anticipated that there will be a substantive fraction of patients who will be contagious, but asymptomatic at the time of surgery.Use multimodal perioperative infection control practices (e.g., including patient decontamination) and monitor performance (e.g., S. aureus transmission from patient to the environment). The consequence of COVID-19 is that such processes are more important than ever to follow because infection affects not only patients but the surgery center staff and surgeons.Dedicate most operating rooms to procedures that are not airway aerosol producing and can be performed without general anesthesia. Increase throughput by performing nerve blocks before patients enter the operating rooms. Bypass the phase I post-anesthesia care unit whenever possible by appropriate choices of anesthetic approach and drugs. Plan long-duration workdays (e.g., 12-h).For cases where the surgical procedure does not cause aerosol production, but general anesthesia will be used, have initial (phase I) post-anesthesia recovery in the operating room where the surgery was done. Use anesthetic practices that achieve fast initial recovery of the brief ambulatory cases.When the surgical procedure causes aerosol production (e.g., bronchoscopy), conduct phase I recovery in the operating room and use multimodal environmental decontamination after each case. Use statistical methods to plan for the resulting long turnover times. Whenever possible, have the anesthesia and nursing teams stagger cases in more than one room so that they are doing one surgical case while the other room is being cleaned.In conclusion, this review shows that while COVID-19 is prevalent, it will markedly affect daily ambulatory workflow for patients undergoing general anesthesia, with potentially substantial economic impact for some surgical specialties.     

Development of a CD-ROM Internet Hybrid: a new thoracic surgery curriculum

The TSDA Prerequisite Curriculum Committee has successfully developed the content for a didactic curriculum to be mastered by the residents before their matriculation in a thoracic surgical residency program. In addition the committee assembled an innovative electronic format consisting of a CD-ROM Internet Hybrid to teach this curricular material. By use of a serialized CD-ROM Internet Hybrid it is possible to store relatively dense high bandwidth portions of the curriculum including video and audio materials on the CD-ROM and yet allow constant updating and interaction of the other portions of the curriculum. In addition, it is possible to track the performance and utilization by the residents during the entire course of their residency program. By studying the relationship between the utilization of the curriculum, particularly as it relates to certain subject areas, and comparing that to performance or standardized examinations as well as other measurements of resident satisfaction, the efficacy of the prerequisite curriculum will be tracked during the upcoming years. It is anticipated that the process of developing the content of the prerequisite curriculum will allow the residents and program directors to focus on the subject material currently deemed necessary for successful initiation of a thoracic surgery residency, and that by keeping this subject material outline up-to-date, the changing spectrum of what we anticipate our residents will know at the time of their matriculation will continue to mature. Although electronic-based education has been available for a number of years, a prospective randomized study comparing it with traditional textbook-based learning is novel. Multiple attempts have been made to implement Web-based or CD-ROM-based educational tools in other specialties with variable results. It is our anticipation that successful completion of this project will not only allow for the use of an innovative highly technical means of education for our residents but may in turn become broadly applicable to many other types of educational projects within thoracic surgery education. This may also be applicable to other types of educational projects in the postgraduate education industry and other venues as well. The conduct of a scientific study monitoring the impact of this curriculum project as well as the acceptance of the project by the resident is also relatively unique and will be scrutinized by numerous professional medical and educational groups.     

Assessing professionalism in surgeons

Professionalism has been identified as one of four domains of competency for surgical trainees in the UK. This implies that professionalism can be learned and assessed. The priorities of different professions and healthcare systems influence the value placed on different components of professionalism and UK surgeons need to identify the characteristics they would most value as part of an effective assessment process. The success of developing a taxonomy of non-technical skills for surgeons (NOTSS) can guide a similar process for a taxonomy for professionalism assessment. A multitude of assessment instruments for professionalism have been described in the literature but very few are valid, reliable or practical. For surgical trainees a number of assessment tools should be considered. A quantifiable tool using multi-source feedback could be the most practical for clinical surgeons to use. It is important, however, that it is not used to assess isolated behaviours but assess conduct within a surgical community of practice, and that the thinking process behind (un)professional behaviour is also understood, especially in stressful situations.     

Evidence and experience: what is the balance in surgeons' training?

Surgeons' training requires professionalism, continuing medical education, and appropriate environment to ensure the desirable success. However, generally, this goal is pursued in an inefficient way, based upon intensive training skills founded in the age-old philosophy of "the way I have learned it". There is, usually, a lack of patient outcome evaluation, especially of long-term follow-up of surgical procedures, which in turns provide little evidence of senior surgeons for adequate training junior surgeons. On the other hand, questioning the established knowledge is not stimulated, or even not tolerated by the seniors. It seems like the "truth" is absolute and allows no change for the new knowledge, which would mean no additional progress. There is a need to significantly alter the implementation of new knowledge, if possible based on evidence, to ensure the best medical care for the surgical patient. Experimental surgery, and nowadays bench model surgery, may be useful in minimizing the predictable complications of patients under the surgeon training responsibility, while on learning curve. Surgery based on evidence should be one of the tools for improving patient surgical care, since this important branch of medical activity must rest on two pillars "art and science"; and surgeon in good training needs to be close to both.     

Realistic expectations and leadership in the era of work hour reform

BACKGROUND: Work hour guidelines and core competencies were introduced to improve surgical education and are changing the landscape of surgical training. We sought to examine perceptions and attitudes regarding the impetus and impact associated with these changes. MATERIALS AND METHODS: Anonymous surveys were distributed to faculty and surgeons-in-training in an Accreditation Council for Graduate Medical Education, university-based, training program. RESULTS: Faculty (F, n = 30) and trainees (T, n = 30) agree that lifestyle expectations and long work hours are the principal issues facing surgical education (F = 80%, T = 56%; P = 0.03). Implementation of ACGME guidelines is perceived as NOT improving patient care or clinical experience (F = 100%, T = 90%; P = 0.03) while reducing operative experience (F = 50%, T = 70%). More faculty (>80%) than trainees (33%) are concerned that ACGME guidelines will diminish patient care experiences. Although most (F = 77%, T = 83%; P = NS) agree that hiring additional providers will improve guideline compliance, many oppose ACGME guideline implementation fearing a loss of professionalism. Although both (F = 50%, T = 47%) admonish deficient interpersonal and communication skills as the major impediment to implementing ACGME guidelines, opinions regarding implementation differ. Most faculty (67%) believe ACGME-imposed deadlines are the most influential reason; however, trainees (57%) believe guidelines should be promptly implemented to address long-awaited changes in work environment and surgical graduate medical education. CONCLUSIONS: Although faculty and trainees' perception of the issues surrounding ACGME guidelines converge, perception of changes following implementation is quite divergent. For successful implementation, leadership must address prevailing attitudes and set realistic expectations. These trends have important implications for planning the future of surgical education, unifying multi-generational colleagues, and improving systems-based practice.     

The health care crisis: impact on surgery from a chief executive officer's perspective

Kaiser Permanente, in conjunction with the surrounding academic institutions, trains 64 surgical residents annually in Northern California. Although the current health care crisis has made resident education increasingly difficult, we are committed to maintaining and expanding our programs. The current health care crisis reflects the effect that for-profit health plans, hospitals, and pharmaceutical groups have had on medicine. Their negative impact has not been simply the extraction of resources from the delivery system to their equity shareholders, but the implementation of an authorization process designed to frustrate and deny. As executive director and chief executive officer of the Permanente Medical Group, I believe that resident training allows us to attract outstanding clinicians, train the physicians of the future, and improve the clinical care of our patients. The multispecialty nature of our medical group and our size allows us to work collaboratively, offer evidence-based approaches, preserve professional independence, and implement innovative programs to increase quality and service. Although it is uncertain how health care will evolve in the future, we at Kaiser Permanente are committed to maintaining and expanding our involvement in the education of the next generation of surgeons.     

Advanced basal cell cancer: Prognosis and treatment philosophy

What may be learned from the unending struggle of this courageous woman to stay alive and recapture her face as cancer repeatedly destroyed it? What does this teach us about both the value and the limitations of our treatment of cancer?The multicentric origin of basal cell cancer and the occult and devious methods by which deep seated lesions spread make cure by surgery extremely difficult. To date, all other methods have an even worse salvage rate. In the face of these facts, should we give up any attempt to control this cancer? And if so, should we give up early or late?Our patient had all of the usual fears of surgery and dread of facial disfigurement that any fastidious and sensitive woman would possess. But her repeated resolution to go through major surgery and her never-changing statements of appreciation for our willingness to “stay with her” and “try once more” to slow the spread of her tumor, make food for thought. The need of many patients for hope—no matter how slight—and for professional activity and candor throughout the battle against cancer is a principal many doctors have learned repeatedly.In cases of advanced basal cell cancer of the face, the surgeon may have to accept the concept of “cancer control” rather than cancer “cure.” The lack of predictability of growth rate of any residual cancer, or of new foci of cancer that may appear, will often frustrate attempts to predict the amount of rehabilitation that reconstructive surgery will provide.One principle stands out. If surgical treatment and the destructive effects of tumor result in the removal of one or more major facial features, it is essential that reasonably prompt reconstruction be undertaken [11]. The identity or self-image of the patient will not tolerate years of waiting for possible recurrence of tumor before repair is undertaken. Late reconstruction after a long cancer-free interval is easier for the surgeon, but it rarely results in the salvage of an effective and intact individual—even when the cure of the cancer has been accomplished [12].Dr. Charles Harrold reminded us that Dr. Hayes Martin believed that “many with advanced cancer could have both a surgical cure and functional rehabilitation” [13,14]. I would suggest that, in certain instances, patients with advanced cancer should have functional surgical rehabilitation even without a surgical cure being likely!Ollie Beahrs [15] has cited Dr. Martin as saying, “It is neither logical nor reasonable for a doctor alone to decide for the patient that certain death from cancer is preferable to even a modest chance for life—even if it is a life without a larynx, tongue, palate, mandible, nose or eye.” Such patients will usually choose the chance for life. We are also learning that when patients know that their cancers cannot be cured, they will often choose to undergo much reconstruction in order to maintain personal identity and human contact during their remaining years of life. Plastic surgery can greatly improve the quality of their lives.     

U.S. health care reform: Will it change postgraduate surgical education?

The principal goals of the pending health care reform initiatives in the United States are improving access to health care and controlling its costs. There are multiple proposals designed to reach these goals. Regardless of the final result, health care reform is likely to have significant implications for postgraduate surgical education. The teaching environment is already rapidly changing. Present environmental influences include the explosion of surgical knowledge, demographic changes, expansion of regulatory requirements from within the health care delivery system and within surgery as a discipline, societal and cultural changes, and economic pressures. Current and pending concerns prompt several questions: What should we teach? Where do we teach? How long should it take? Who are our learners? How do we evaluate our educational programs? Who should pay? A number of predictable changes affecting surgical education are proposed. New, more complex technologies will result in increased surgical specialization. Demands on surgical education will require that it be shorter, more relevant, more efficient, more effective, and more accountable. Surgical manpower requirements must be more clearly defined. Better and more relevant measures of clinical outcomes will be developed. Use of improved informational technology to manage clinical activity will expand. Solutions to the problem of foreign medical graduates will be clarified. The issue of who pays for surgical education will require resolution with some new and creative results. A proposal for shorter and more effective surgical residency is advocated.     

Geriatrics for surgeons: infusing life into an aging subject

PURPOSE: Geriatric patients have specific medical and social needs for which surgeons must become adept at caring. In an effort to improve the care of the elderly, we have committed to developing a geriatric component for our surgical curriculum that is part of our PGY2-protected block curriculum. Competencies covered by this curriculum plan include medical knowledge, systems-based practice, professionalism, patient care, practice-based learning, and communication skills. METHODS: The geriatrics curriculum is imbedded in our current protected block curriculum and includes 5 separate sessions during the PGY2 year. During the protected block curriculum, the residents (N = 7) are relieved of all clinical activity, including call. A needs assessment survey assessed the residents' perceptions of the residency program's current focus on geriatric principles. The geriatric portion of this curriculum uses small-group instructional methods consistent with adult learning principles that include practice-based learning, case-based learning, patient simulation using Objective Structured Video Examination (OSVE), and didactic sessions. Faculty instruction is a shared responsibility between geriatricians and general surgeons. The longitudinal geriatrics curriculum includes approximately 10 hours of learner activities over a single-year period. EVALUATION: The curriculum will be evaluated by assessing participant knowledge through the use of multiple-choice testing. Resident performance on OSVEs will likewise be assessed. This method will allow for assessment of higher decision making and clinical reasoning. Finally, a family meeting OSCE will be used to assess professionalism and communication skills further. Overall, all 6 competencies will be assessed using our specific assessment tools. The curriculum content and instructional delivery will be evaluated using longitudinal and session evaluation forms. RESULTS AND EXPERIENCE TO DATE: The geriatrics curriculum will be implemented fully over 2 years. Three sessions will be introduced during the 1st year, and 2 more will be implemented in the 2nd year. The needs assessment survey results demonstrated a lack of sufficient educational focus on geriatrics topics and a low comfort level in caring for the elderly patient. The 1st session of the curriculum has taken place with positive results. The 1st session was a case-based session that focused on critical care and end-of-life issues in the elderly. Although the medical knowledge data are limited thus far, the average pretest score was 57% compared with the 86% posttest score. The resident evaluations (N = 7) of the session demonstrated an average 4.7 (1-5 Likert scale) for content and a 3.9 (1-4 Likert scale) for instructional delivery. CONCLUSION AND NEXT STEPS: Elderly surgical patients have multiple challenges. Specific geriatric training for surgical trainees is lacking. Over the next 2 years, the curriculum will be developed and evaluated even more for its ability to provide adequate instruction in the specific care of the elderly surgical patient. The ultimate goal is to improve the care of the elderly surgical patient.     

Changing patterns of surgical training and practice

Surgeons who are completing their training should be enabled to assume final patient responsibility for 1 year in an environment where they can easily obtain advice and guidance. A cooperative adjustment in the number of surgical specialists should be made as long as inadequately qualified physicians are appropriately retrained. Separate training programs should be considered to emphasize experience with frequently performed low-risk procedures. Equitable entrance requirements should be established for all graduates of various preparatory health care schools not endorsed by the CCME who might be qualified for admission to approved surgical training programs and subsequent Specialty Board examinations.We should be prepared to assist in the making of difficult recommendations regarding priorities in the expenditure of health care dollars as funds become increasingly restricted. A surgeon's performance should be monitored in his hospital and as long as he meets locally approved standards of practice, all other quality control measures should be optional. The development of surgical investigators should be encouraged by providing financial and job stability during the prolonged period required for research and surgical training.Much of what I have said regarding medical education, practice and research is related to the role of the government. What will be the rules and regulations of the government under which our schools must operate and our surgical practice and research be conducted in the future? How much money will the government offer to support education and research, and what funds will be available for patient care? Obviously, the profession has taken on a big, aggressive, domineering partner in all of these fields since many of us graduated from medical school. Our governmental partner is fairly new to the problems of medicine, but since many of today's problems are also new to us, we must learn to work effectively with the government and all of its agencies as we attempt to meet the challenges of the future.     

When things go wrong: protecting patients and supporting doctors

A healthcare system should ensure that surgical errors are kept to a minimum, and if possible are avoided altogether. Unfortunately, errors do occur however carefully one tries to avoid them. Once recognized an error must be rectified as soon as possible. An appropriate apology to the patient or their relative is an absolute requirement. In this article I review the processes available to deal with errors both locally and through the regulatory authorities if considered necessary. I look at how lapses, both clinical and non-clinical, are handled locally and by the appropriate regulatory body. I also discuss how allegations relating to fitness to practise are investigated. Whilst the over-riding responsibility of all these structures is to protect patients, as mentioned it is necessary also to support doctors and to learn the lessons on how and why the errors have occurred. The maintenance of professionalism is essential. As well as supporting and protecting the patient, support for the surgeon in the workplace is a necessary requirement.