Perspective: Who Will That be, Behind the Mask?

NASHVILLE -- Imagine 20 years from now you are broadsided at an intersection, cut out of your car by advanced emergency medical specialists, taken to a modern emergency room, prepared for urgent surgery. As you are wheeled into the operating room and lifted over onto the cold table, you squint up a backlit face, silhouetted by the intense beams of the surgical lamps. Who is this, exactly, standing over you with the sharp object in her hand?

It won't be Marcus Welby, that is certain. And it may be a very different person than you see on any present-day television program, because the training of young surgeons is changing as fast, or faster, than the times. Today's would-be surgeons are not signing up for the rigorous training, long nights and boot camp atmosphere that has defined surgical training programs since the early 1900s.

As the anesthetic mask is lowered over your face, you may wonder whether your surgeon is well trained. Is she seasoned by experience? Not distracted by medical politics? Rested? Happy at home? You may wish that these issues had been adequately considered way back in 2001.

Those questions were discussed here recently at the annual meeting of the Association of Program Directors in Surgery. The facts aren't reassuring. Fewer medical students find the price paid for surgical training to be worth the reward of being a surgeon. Women in particular find the prospect of surgery training to be largely incompatible with starting a family. With medical schools composed of 50 percent women, that diminishes the pool of applicants right there. The siren call of the dot-com economy, the lure of the investment banking world, the good life all beckon. Well-trained surgeons in their 50s have reached the same conclusion. They are retiring earlier than they expected, fed up with HMOs, shrinking reimbursements, regulations and loss of prestige. Up until very recently, the market has been good to them, too. This means fewer surgeons to serve the population.

This year was a dry one for attracting bright medical students into surgical residency programs. Forty of the 200 or so surgical training programs failed to "fill" their quota of approved residency slots with incoming interns. One participant here called this circumstance a "catastrophe of biblical proportions."

How did we get to the point where the Bible has to be invoked to describe the crisis? It is a curious history. Surgeons were originally derived from medieval barbers and were skilled at bloodletting, amputation and very little else. Not until anesthesia was developed in the mid 19th century did surgery even begin to become a practical way to treat disease. At the turn of the last century anyone graduating from a medical school could call himself (almost all were men in those days) a surgeon. Sometimes graduates served apprenticeships with more experienced surgeons, sometimes not. By the early 1920s surgical training became more organized as many universities adopted residency programs modeled after the famous Johns Hopkins program developed by William Stewart Halsted. In this program, several interns were selected to compete for the privilege of training in surgery. Those who succeeded spent eight to 10 years living in the hospital (hence the term resident), gaining experience and ultimately operating on indigent patients as surgeon in charge. Those not chosen drifted into other specialties like ob-gyn, urology, etc.

With some changes, this is the type of program I entered in 1970. Fourteen interns competed for four chief resident positions; we took anywhere from five to eight years to complete training. Although we had apartments and were allowed to be married, most of that time we spent every other night in the hospital and worked every other weekend from Saturday morning until Monday night. We were driven by a love of surgery, admiration for our surgical heroes and competitive instincts. This was just the way it was. We were glad to be in the running. Two from that group now serve as chairmen of academic surgical departments today.

By the mid-'70s several important changes were in the wind. Medicare mandated the end of the "two-tiered" system, and all patients treated in training programs were operated on by attending surgeons with residents. This was good for the patient but depleted the independent experience of the resident. Instead of doing a complex operation alone for the first time in a teaching hospital with experienced help down the hall, young surgeons were now doing their first unsupervised procedure on a paying patient after the end of training. This important milestone of independent responsibility is unique to surgery. There are no simulators for open-heart operations like there are for flying a 747. In fact, most experienced surgeons will admit that it takes another five to 10 years after finishing a residency to get the judgment and skill to be really good at surgery. This makes the surgeon about 40 years old before he or she hits a competent stride.

Gone, too, is the competitive "cut." Incoming interns are now guaranteed a slot to finish training when they are admitted to a program. And the working conditions are somewhat better, in part because of Libby Zion. Zion was a young woman admitted to the New York Hospital-Cornell Medical Center on March 5, 1984. She had fever, dehydration, and rigors and was admitted to the medicine service after being seen by medical residents who conferred with her primary physician by phone. She did not give an accurate history of her drug usage and was subsequently given drugs that should not be given to anyone taking the phenelzine and cocaine that she had taken. She was restrained for agitation. She seemed to get better, then died suddenly at 6:30 a.m. The medical examiner attributed her death to broncho-pneumonia and questioned the role of the drugs found in her bloodstream.

Libby's father was an attorney who wrote for the New York Times. He took his suspicion to Robert Morgenthau, New York's district attorney. He convened a grand jury, which, although it returned no indictments, faulted the residency system for Ms. Zion's death. The grand jury made five recommendations, two of which dealt with resident supervision and limits to resident work hours.

This tragic death led to a media stampede about "restless" doctors and ultimately to the regulations that stipulated no resident in New York State could work more than 80 hours a week and have less than one day off in seven. This posed an enormous challenge to hospitals with residencies. They had become addicted to using residents as low-cost labor. Residents were bright, motivated and cost half as much as nurse practitioners or physician assistants. Hospitals immediately quoted huge fiscal losses at a time when other pressures were already holding the bottom line hostage.

There's been some negotiating since, and there's a proposal by the Residency Review Committee for Surgery that surgical residents be allowed to have as much as 96 hours of duty time per week. For perspective, that's two 40-hour weeks, plus two eight-hour days, per week, and this is an improvement.

Where does this leave today's young medical students as they contemplate a future in medicine? Saddled with an average of more than $100,000 in debt, eager for today's lifestyle of immediate wealth, and often married with young children, surgery looks like a poor choice. One can get the technical and dramatic thrills of surgery by doing emergency room medicine and be home by six. No messy follow-up care. "Clean" fields, like ophthalmology./040801/Perspective/Who_Will_That_be__Beh.shtml