RIPPLES

Program chairmen and directors and other surgical educators make decisions about surgical education that will have a ripple effect onresidents, and eventually, medical students. This section is designed to show you residents’ perspectives and thoughts about issues in surgicaleducation that affect their lives, their education, and their treatment of patients. In each issue, 3 residents from across the nation will be askedto write their response to a question, given to them by the editorial staff. This issue’s question is “What are your expectations for your futurepractice?”

Looking Forward to the Unknown

Benjamin Samstein, MD

Columbia University Medical Center, New York Presbyterian Hospital, New York, New York

Preparing to finish our residencies, increasingly my col-leagues and I are focusing on life after formal training. As inprevious years, most of the graduates from our program arecontinuing their training in the form of a fellowship. Fre-quently, the fellowships are chosen with practice expectations inmind. We are trying to figure out which macrotrends and mi-crotrends will continue and when the pendulum of opportunitywill reverse direction. We are attempting to position ourselvesfor changes on the horizon and changes not yet anticipated.However, little during training prepares residents for practice.There is minimal exposure to selecting a practice, building apractice, billing, grant writing, or management techniques. Asin residency, much will be on-the-job training. I have focusedon trends that have changed practice since I began in surgery 7years ago. Below I discuss the move away from specific tech-niques, the overblown concerns about work-hour limits, theimpact of information technologies on surgical training andpractice, and the continuing strain that the cost of medicaleducation places on surgery. What follows are mostly hopes,tempered by pessimism and wishes unencumbered by experi-ence.

Surgery in the 21st century will continue to become moredisease oriented than technique oriented. Surgeons will need tobe able to use a number of different techniques to treat disease.For example, surgeons treating hepatocellular carcinoma arebest able to care for their patients if they can use open andlaparoscopic techniques as well as percutaneous ablative tech-niques and, perhaps, endovascular embolization. Surgeonsmarried to any one technique will see their practices dwindlebecause I expect, more than anything else, that the pace ofchange in medicine and surgery will accelerate in the comingdecades. Surgeons will be more effective and have a more sus-

tainable future as part of teams that use multimodality ap-proaches.

To learn these new approaches, training, short of full fellow-ships, in new techniques is becoming more routine. At ourinstitution, we have seen the development of the mini-fellow-

Correspondence: Inquiries to Benjamin Samstein, MD, Columbia University Medical Cen-ter, New York Presbyterian Hospital, Milstein Hospital Building, 177 Fort WashingtonAvenue, Room 76S-313, New York, NY 10032; fax: (212) 305-8321; e-mail:bsamstein@yahoo.com

Benjamin Samstein, MD

CURRENT SURGERY • © 2004 by the Association of Program Directors in Surgery 0149-7944/04/$30.00Published by Elsevier Inc.

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ship, where established surgeons learn new techniques, such asendovascular surgery, during a 3-6-month training programsperiod. Advanced laparoscopic techniques, bariatric surgery,robotic surgery, and other novel approaches to disease requiremore than weekend courses. General surgery and specialtytraining will serve as a basis on which to master new techniques.Formal training cannot last forever, and in fact, it appears likelythat formal general surgery training will be shortened to 3 or 4years within a decade.

The new ACGME regulations have produced a great time ofconcern among surgical educators, surgeons, and current train-ees. The forces are pulling in opposite directions, students andresidents calling for fewer years in training and the public call-ing for fewer hours per week. Although all are interested inincreased efficiency of training, it is clear that there is conflictbetween those who want the 80-hour week and those who wantto practice and train faster. Some of my colleagues believe thatsoon we will be see calls for even shorter weeks, similar to workhours in parts of Europe.1 I believe that the current focus onhours is misplaced and will be relatively short-lived. Although itis unlikely that the work-hour regulations will be rescinded, I donot see progressively shortened workweeks for surgeons or res-idents. The primary goal of work-hour reduction, from thepublic standpoint, is the minimization of fatigue-induced iat-rogenic injuries. Medication errors, inappropriate dosages, aremore effectively prevented by computerized order entry andpharmacy systems that will be in place within 10 years. Infor-mation technology, in fact, has tended to increase connectivityof workers by use of mobile phones, pagers, and email. Cowork-ers and patients have rapidly gotten to use to physicians nearlyalways being accessible. It seems likely, going forward, patientswill desire to be more connected with their caregivers, not less.

Information technology will not only impact who deliverscare, but also the way we train residents. Over the next decade,we are going to see a transformation in residency training, mak-ing residency more didactic and educational oriented and lessprimary responsibility for patient care. Residents will be ex-posed to patient care scenarios and tested for competency priorto caring for patients. Internet-based training2 is likely to pro-liferate. Computers can be used to expose and test residents onclinical scenarios that occur both routinely and rarely. Improve-ments in computer technology will make training in simulatorsmore interesting. Investment in computer simulators may wellprove too expense for individual programs and hospitals, andtraining may need to take place at regional centers where pooled

resources support training simulators. Training residents andeducating medical students will become more expensive.

The cost of medical education and training is a major obsta-cle facing American surgery today. Medical students enteringColumbia University College of Physicians and Surgeons in2004-2005 face estimated tuition and fees of just shy of$40,000. Including living expenses, annual expenses are esti-mated at approximately $60,000 per year. If a student chose ageneral surgery residency, he/she might well owe nearly$400,000 by the summation of 5 years of clinical training[based on 2 years of research during resident, 2 years of fellow-ship, and 5% annual interest]. This level of debt of surgicaltrainees dramatically impacts on quality of life, and directly onfellowship and research decisions. The National Institutes ofHealth has recognized this by expanding loan forgiveness pro-grams to physicians involved in clinical research. However, pro-gression of this trend will lead to crushing debt that drivesyoung people away from surgery. It is likely that student debtwill need to reach crisis proportions before we reconsider thefinancing of medical education. Attempts to ameliorate the sit-uation by shortening surgical training or focused loan forgive-ness programs will not address the fundamental issue. This issueand the cost of resident education must be addressed on a na-tional scale for the surgery and medicine to thrive in the comingcentury.

I look forward to my future practice with enthusiasm. Therewill always be pressures and strains on the surgeon-patient re-lationship. I am excited to apply what I have learned and to helpdevelop new innovations. I believe that the current focus onwork hours will be replaced by attention to outcomes. The issueof the cost of medical education must be addressed for thecontinued success of surgery and medicine. Fundamentally, pa-tients will continue to seek out surgeons and physicians wholisten to them, demonstrate caring and concern, and improvetheir lives.

REFERENCES

1. Goldstein M. Surgical training, the revolution: work hourslimitations. Curr Surg. 2003;60:321-323.

2. Schell SR, Flynn TC. Web-based minimally invasive sur-gery training: competency assessment in PGY 1-2 surgicalresidents. Curr Surg. 2004;61:120-124.

doi:10.1016/j.cursur.2004.03.004

396 CURRENT SURGERY • Volume 61/Number 4 • July/August 2004