Vol. 68, No. 6
475
Current Status of Surgical Education, Resident Training and Continuing Education H. WILLIAM SCOTT, JR., M.D., F.A.C.S.,* Professor of Surgery and Director, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee and President, American College of Surgeons
is a great pleasure to be a part of this ITprogram and I thank you very much for
asking me to participate. It is also a great pleasure to be in a medical center in my city of Nashville where progressive, modern building has taken place so recently and so impressively and according to the newspapers a great deal more is to come! I want to extend my heartiest congratulations to my Meharry colleagues on their splendid acomplishments and great vision. Dr. Bernard has asked me to talk on the current status of surgical education, resident training and the continuing education of practicing surgeons. To do this, I shall draw heavily on two reports which have been published in the last year: 1) "Surgery in the United States,"' which is the 1975 summary report of the study on surgical services for the United States chaired by Dr. George Zuidema which was carried out under the joint sponsorship of the American College of Surgeons and the American Surgical Association. 2) "Physicians for the Future"2 which is the 1976 report of the Macy Commission chaired by Dr. Dale Corson under the sponsorship of the Josiah Macy, Jr. Foundation of New York City. As you know, the SOSSUS Report is concerned with the status of surgical services including surgical manpower, allied personnel and multiple related facets of the activities of surgeons including their distribution in this country. It is an enormous and unique studythe most exhaustive ever made of its sub*Read before the Surgical Section of the National Medical Association at Nashville, Tennessee on August 9, 1976.
ject. Every surgeon in this country is indebted to Dr. Zuidema and his collaborators for carrying it to completion. I urge those of you who have not read the summary report to do so. You are well aware that the summation of the educational forces, spear-headed by the Flexner Report3 in 1910 with its profound effects on American medical schools, the founding of the American College of Surgeons in 1913 with its enormous influence in elevating standards of surgical care, have combined with the growth of residency programs to produce a very large number of highly competent surgeons who have, I believe, done an excellent job in the care of their patients in this country in the last half century. Dr. Francis D. Moore in the Surgical Manpower Section of the SOSSUS Report4 gives the following estimates of the numbers and qualifications of people who perform major operative surgery in the United States as of 1975. Based on a total of 380,000 physicians of whom 309,000 are engaged in the care of patients, 16.8% or 52,000 are Board certified surgeons. When one adds to this group of 52,000 surgeons the 12,000 surgical residents in training in approved programs, there is a total force of 64,000 Board certified surgeons and their postgraduate students. In addition, there are approximately 20,000 non-Board certified surgical specialists, 9,000 general practitioners and 1,500 osteopaths who do surgical operations. The grand total of professionals who carry out surgical operations as a major feature of their practice is 94,000 (approximately 30% of all active practitioners).
476
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
In a statistical overview of the surgical manpower data in the SOSSUS1 Report, the evidence according to Dr. Moore has suggested that "between 50,000 and 60,000 Board certified surgeons, together with 10,000 to 12,000 interns and residents, would prove sufficient for surgical care in the United States for the next 40 to 50 years." This strong statement assumes not only the validity of the data from which the projections are made, but equal validity in estimates of growth and distribution of population and in distribution of surgeons and services both now and in future decades. However, it is a challenging and most provocative statement made by an expert. The OSSUS1 study points out that the widespread notion that we have more surgeons in this country than the nation needs is based on the use of the term "surgeon" by third party payors and national agencies to describe anyone who undertakes a performance, however infrequently, of what they deem to be a surgical procedure-including radiologists doing arteriograms, cardiologists carrying out cardiac catheterizations and the like. This indiscriminate practice produces a falsely inflated estimate of the number of surgeons as well as surgical procedures. The American College of Surgeons has defined a surgical specialist as a physician who: a) is certified by an American surgical specialty board approved by the American Board of Medical Specialties or b) by reason of his education, training and experience has been judged eligible by such a board for its examination or c) is a Fellow of the American College of Surgeons or d) has obtained in a country outside the United States graduate surgical education which satisfies the training requirements for fellowship in the American College of Surgeons. The College recognizes that surgical procedures may also be performed by physicians who do not meet this definition under the following conditions: 1) a physician who received the M.D. degree prior to 1968 and who had had full surgical privileges for over five years in a hospital approved by the
NOVEMBER, 1976
Joint Commission on Accreditation of Hospitals where most of his surgical practice is conducted or 2) a physician who renders surgical care in a) an emergency or b) an area of limited population where surgical specialist is not available or 3) a physician who has just finished formal training in an approved surgical residency program as defined in his specialty for whom the appropriate surgical board has not yet determined eligibility. The College, of course, recognizes and endorses the concept that a resident in training in an approved surgical program under supervision may provide surgical care as determined by the surgical staff. The SOSSUS1 study suggests that the number of Board qualified and Board certified surgical specialists is reasonable, both in absolute numbers (54,000) and in ratio to the population (24 per 100,000). However, according to the report the number of persons carrying out surgical operations in the United States is excessive, constituting approximately 30.4% of all active practitioners. In addition, the SOSSUS1 report indicates that the number of surgical residency positions offered annually in this country, approximately 16,000, is also excessive. The number of persons now entering and completing surgical residency each year (2,500 to 3,000) is larger than that required by population needs. SOSSUS estimates that the number of highly qualified, highly trained and well motivated young men and women entering the practice of surgery each year should be in the neighborhood of 1,600 to 2,000 persons during the period 1976 to 2012. The problem of an excessive number of persons doing surgical operations can be solved according to SOSSUS1 only by stricter hospital regulations for the granting of surgical privileges. The problem becomes particularly important as legislation is proposed for universal prepaid tax supported health care. Strict specifications of surgical credentials should be included in any such legislation.
Vol. 68, No. 6
Continuing Education
Board certification, although important, should not be the only criterion; guidelines should also recognize maintained productive interest, clinical activity, maintenance of knowledge and skills by education and the desire of physicians to change, increase or modify their educational qualifications. Surgical privileges should be examined during hospital surveys for audit or accreditation. SOSSUS1 thinks that a necessary condition for monitoring and controlling surgical residency positions and Board certification rates is the strict limitation of hospital privileges for the performance of major surgical operations. Without this control at the level of practice monitoring or control of the number in training becomes meaningless. The SOSSUS1 report emphasizes that the public's acceptance of stricter hospital credentialling imposes on surgeons an obligation to establish proof of continuing education and continued physical and intellectual fitness by examinatlion, local board review or recertification. SOSSUS' stipulates that there are three components in the improvement of manpower standards for surgery in the United States. These three must be strengthened and maintained as a combined program since they are mutually reinforcing: 1) continuous monitoring and control of residency output and Board certification rates 2) stricter hospital credentialling 3) periodic reassessment of fitness, performance and competence. It is often alleged that there is a nonuniform distribution of surgical services by location and by surgical specialty. The bulk of the surgical manpower data in the SOSSUS' report is concerned with the distribution of surgical specialties. SOSSUS' finds that aside from the expected greater concentration in urban than in rural areas surgeons are remarkably evenly distributed throughout the country-apparently more evenly than are other medical specialists. Despite a relative abundance of surgeons (per hundred thousand) in the northeast, middle Atlantic, northwest and Pacific coast
477
regions, the remainder of the country is not underserved and the regional discrepancies are not large as compared to other medical specialties. Throughout the country there are approximately forty surgeons per one hundred thousand in the cities and twenty per cent per one hundred thousand in the rural areas. SOSSUS1 finds the distribution of surgeons to be more closely correlated with availability of hospital beds than with any other single factor. The mean for the country, based on the average for the states, is 15 hospital beds per surgeon, the urban figure being lower ( 1) and the rural figure higher (25). Since many of the diseases treated by surgeons demand large and complex facilities, a non-uniform distribution of services cannot be equated with substandard care, provided access and transportation are adequate. In general the SOSSUS1 data show the distribution of the most numerous surgical specialists (Board certified) namely general surgeons, obstetrician-gynecologists and orthopedists by state, census district and city to be remarkably even. In both the distribution of surgeons and the relationships among the various surgical specialties it is clear that the free system of career choice and location for practice has served rather well. To quote Francis Moore, "While there are some regional inequities, and one might consider some of the specialties over populated, the overall distribution of surgeons would be very difficult to improve by forceable constraint, obligatory service or penalties for failure to follow legal directions.' Currently, and possibly not for long, medical licensure is adjudicated by the state. The certification of surgical and other medical specialty competence by examination after completion of graduate education is done by the American Boards-in the voluntary or private sector. Accreditation of medical schools and hospitals is done by voluntary agencies. Residency programs are reviewed by voluntary residency review committees and these committees' actions are approved or disapproved by the Liaison Committee on Graduate Medical Education
478
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
-a voluntary group with representation from the AMA, AHA, AAMC, ABMS and the CMSS (Council of Medical Specialty Societies). Above the LCGME in this hierarchy is the Coordinating Council on Medical Education (CCME) established in 1972-73 with similar representation and sponsorship by the great voluntary organizations. The CCME is designed to serve as a supervisory body concerned with policy matters and accreditation of all levels of medical education. Continuing education is abundantly available throughout the country to physicians and surgeons through our university and hospital postgraduate programs, and our local, regional and national organizations such as the National Medical Association and the American College of Surgeons. However, ladies and gentlemen, this voluntary system of ours is under fire from all sides-the heaviest bombardment comes from the banks of the Potomac. Let me briefly list some of the facts. First of all this year the Macy Commission2 published its study of problems of paramount medical concern, touching on the changing supply and distribution of physicians, primary care, graduate medical education, continuing education and many other problems reviewed by the SOSSUS' study. Taken together these issues raised the question of whether there existed an organization in the voluntary sector that could conduct continuing analyses of these problems and recommend corrective solutions. The Macy Commission2 consensus was "no". The Commission recommends the establishment of a new National Commission on Medical Education, Manpower and Services which would coordinate the efforts of other functioning organizations including federal agencies, into a "meaningful national policy in medical education, manpower and medical services". My personal bias opposes the need for such a commission and my concern is that it would become organized, funded and controlled by the federal bureaucracy. In this regard as of June, 1976 the Department
NOVEMBER, 1976
of Health, Education, and Welfare has published the proposal for credentialing health manpower which includes a national system for certification, national standards, federal reimbursement for health care services limited to those with licensure in states with federal standards, proficiency examinations, relicensure and recertification. This proposal ends as follows, "the subcommittee urges that additional support be given to the development of more sophisticated approaches to continued competence which ultimately can be tied into a mandatory recertification or relicensure requirement". As most of you know, voluntary re-examination and recertification is already being offered to diplomates of several boards including, I believe, the American Board of Internal Medicine. The American Board of Surgery will begin its voluntary recertification program in 1980. Literally thousands of surgeons in the last few years have taken, voluntarily, the self-assessment examinations, SESSAP I and II, offered by the American College of Surgeons. I believe American surgeons prefer the word "voluntary" to the bureaucrat's "mandatory". The Senate has passed S 3239,5 the Health Manpower Act of 1976, under the sponsorship of Senator Kennedy. As many as you may know, this Bill proposes to amend the Public Health Service Act to revise and extend the programs under title VII for training in the health professions, to expand the National Health Service Corps and provide scholarships for medical students who will serve in areas of need, and to sponsor training programs in primary care and family medicine. What you may not know is that the current, Senate passed bill has a feature aimed at correction of what Senator Kennedy perceives to be the maldistribution of medical specialists and residency positions by establishing a National Council on Postgraduate Physician Training and 10 regional councils. Mr. Kennedy proposes that after two years of study, the National Council will annually determine the total number of graduate physician training positions and allocate these positions among the various
Vol. 68, No. 6
Continuing Education
specialties and subspecialties. Using a formula as a limit related to a percentage in excess of the number of graduates of medical schools, the National Council will then distribute the total number of residency positions to the ten national regions. The regional councils are to assign the positions allocated to them to the approved programs of graduate medical education in their region. There is much more in this bill, including a proposal to determine the cost of "educating" students as chiropractors in the future. Mr. Kennedy, as usual, is busy at his self-appointed task of regulating physicians and developing more and more federal controls over medical education and medical practice. In closing let me quote from the final paragraph in Dr. Robert Chase's chapter on Government Relations in the SOSSUS report: "Only influence by health professionals can avoid the dangers expressed by Justice Brandeis: 'Experience should teach us to be most on our guard when the government's purposes are beneficent. Men born to freedom are naturally alert to repel invasion of their liberty by evil-minded
479
rulers. The greatest dangers to liberty lurk in insidious encroachment by men of zeal, well-meaning but without understanding'."6 LITERATURE CITED
1. Surgery in the United States. A Summary Report of the Study on Surgical Services for the United States. Chairman G. Zuidema. Sponsored jointly by the American College of Surgeons and the American Surgical Association. Ed., R. A. Potter, 1975. 2. Physicians for the Future-Report of the Macy Commission, Chairman D. Corson. Sponsored by the Josiah Macy, Jr. Foundation. New York. 1976. 3. FLEXNER, ABRAHAM. Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching. Boston, D. B. Updyke, the Merrymount Press, 1910. 4. A Proposal for Credentialing Health Manpower. U.S. Department of Health, Education and Welfare, Public Health Service, Health Resources Administration, June, 1976. 5. S 3239, the Health Manpower Act of 1976. Introduced by Senator Kennedy, 94th Congress 2nd Session, April 1, 1976. Senate Report No. 94-887, Congressional Record. 6. Justice Brandeis: quoted in Chapter XII, p. 202 of SOSSUS report (1) .
(Diggs anid Flowers, from page 493)
4. SHOPE, E. S. and C. VORDER BRUEGGE, L. W. DIGGS, F. 0. RAASCH, and F. M. KING. Sudden Death in Unsuspected Sickle Cell Disease. Read at Am. Soc. Clin. Path. Meeting, Boston, Mass., April 15, 1971. 5. News from the Bench and Examining Room: Sickling Suspected in Football Death. Physician and Sports Medicine, p. 21, October, 1974. 6. MURPHY, J. R. Sickle Cell Hemoglobin (Hb AS) in Black Football Players. J.A.M.A.,
225:981-982, 1973. 7. DIGGS, L. W. and R. WALKER. A Solubility Test for Sickle Cell Hemoglobin, 1. Aggregation and Separation of Soluble and In-
soluble Components without Centrifugation. Lab. Med., 4:27-31, 1973. 8. NAUMANN, H. N. and L. W. DIGGS. Screening Reagent for Hemoglobin S (Hb S). J.A.M.A., 227:1262, 1974. 9. DIGGS, L. W. and C. F. AHMANN, and J. BIBB. The Incidence and Significance of the Sickle Cell Trait. Ann. Int. Med., 7:769778, 1933. 10. DIGGs, L. W. and L. BARRERAS, and R. JOYNER. The Test Tube Turbidity Method as a Screening Procedure for the Detection of Sickle Cell Hemoglobin. Memphis and MidSouth Med. J., 44:313-317, 1969.
475
Current Status of Surgical Education, Resident Training and Continuing Education H. WILLIAM SCOTT, JR., M.D., F.A.C.S.,* Professor of Surgery and Director, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee and President, American College of Surgeons
is a great pleasure to be a part of this ITprogram and I thank you very much for
asking me to participate. It is also a great pleasure to be in a medical center in my city of Nashville where progressive, modern building has taken place so recently and so impressively and according to the newspapers a great deal more is to come! I want to extend my heartiest congratulations to my Meharry colleagues on their splendid acomplishments and great vision. Dr. Bernard has asked me to talk on the current status of surgical education, resident training and the continuing education of practicing surgeons. To do this, I shall draw heavily on two reports which have been published in the last year: 1) "Surgery in the United States,"' which is the 1975 summary report of the study on surgical services for the United States chaired by Dr. George Zuidema which was carried out under the joint sponsorship of the American College of Surgeons and the American Surgical Association. 2) "Physicians for the Future"2 which is the 1976 report of the Macy Commission chaired by Dr. Dale Corson under the sponsorship of the Josiah Macy, Jr. Foundation of New York City. As you know, the SOSSUS Report is concerned with the status of surgical services including surgical manpower, allied personnel and multiple related facets of the activities of surgeons including their distribution in this country. It is an enormous and unique studythe most exhaustive ever made of its sub*Read before the Surgical Section of the National Medical Association at Nashville, Tennessee on August 9, 1976.
ject. Every surgeon in this country is indebted to Dr. Zuidema and his collaborators for carrying it to completion. I urge those of you who have not read the summary report to do so. You are well aware that the summation of the educational forces, spear-headed by the Flexner Report3 in 1910 with its profound effects on American medical schools, the founding of the American College of Surgeons in 1913 with its enormous influence in elevating standards of surgical care, have combined with the growth of residency programs to produce a very large number of highly competent surgeons who have, I believe, done an excellent job in the care of their patients in this country in the last half century. Dr. Francis D. Moore in the Surgical Manpower Section of the SOSSUS Report4 gives the following estimates of the numbers and qualifications of people who perform major operative surgery in the United States as of 1975. Based on a total of 380,000 physicians of whom 309,000 are engaged in the care of patients, 16.8% or 52,000 are Board certified surgeons. When one adds to this group of 52,000 surgeons the 12,000 surgical residents in training in approved programs, there is a total force of 64,000 Board certified surgeons and their postgraduate students. In addition, there are approximately 20,000 non-Board certified surgical specialists, 9,000 general practitioners and 1,500 osteopaths who do surgical operations. The grand total of professionals who carry out surgical operations as a major feature of their practice is 94,000 (approximately 30% of all active practitioners).
476
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
In a statistical overview of the surgical manpower data in the SOSSUS1 Report, the evidence according to Dr. Moore has suggested that "between 50,000 and 60,000 Board certified surgeons, together with 10,000 to 12,000 interns and residents, would prove sufficient for surgical care in the United States for the next 40 to 50 years." This strong statement assumes not only the validity of the data from which the projections are made, but equal validity in estimates of growth and distribution of population and in distribution of surgeons and services both now and in future decades. However, it is a challenging and most provocative statement made by an expert. The OSSUS1 study points out that the widespread notion that we have more surgeons in this country than the nation needs is based on the use of the term "surgeon" by third party payors and national agencies to describe anyone who undertakes a performance, however infrequently, of what they deem to be a surgical procedure-including radiologists doing arteriograms, cardiologists carrying out cardiac catheterizations and the like. This indiscriminate practice produces a falsely inflated estimate of the number of surgeons as well as surgical procedures. The American College of Surgeons has defined a surgical specialist as a physician who: a) is certified by an American surgical specialty board approved by the American Board of Medical Specialties or b) by reason of his education, training and experience has been judged eligible by such a board for its examination or c) is a Fellow of the American College of Surgeons or d) has obtained in a country outside the United States graduate surgical education which satisfies the training requirements for fellowship in the American College of Surgeons. The College recognizes that surgical procedures may also be performed by physicians who do not meet this definition under the following conditions: 1) a physician who received the M.D. degree prior to 1968 and who had had full surgical privileges for over five years in a hospital approved by the
NOVEMBER, 1976
Joint Commission on Accreditation of Hospitals where most of his surgical practice is conducted or 2) a physician who renders surgical care in a) an emergency or b) an area of limited population where surgical specialist is not available or 3) a physician who has just finished formal training in an approved surgical residency program as defined in his specialty for whom the appropriate surgical board has not yet determined eligibility. The College, of course, recognizes and endorses the concept that a resident in training in an approved surgical program under supervision may provide surgical care as determined by the surgical staff. The SOSSUS1 study suggests that the number of Board qualified and Board certified surgical specialists is reasonable, both in absolute numbers (54,000) and in ratio to the population (24 per 100,000). However, according to the report the number of persons carrying out surgical operations in the United States is excessive, constituting approximately 30.4% of all active practitioners. In addition, the SOSSUS1 report indicates that the number of surgical residency positions offered annually in this country, approximately 16,000, is also excessive. The number of persons now entering and completing surgical residency each year (2,500 to 3,000) is larger than that required by population needs. SOSSUS estimates that the number of highly qualified, highly trained and well motivated young men and women entering the practice of surgery each year should be in the neighborhood of 1,600 to 2,000 persons during the period 1976 to 2012. The problem of an excessive number of persons doing surgical operations can be solved according to SOSSUS1 only by stricter hospital regulations for the granting of surgical privileges. The problem becomes particularly important as legislation is proposed for universal prepaid tax supported health care. Strict specifications of surgical credentials should be included in any such legislation.
Vol. 68, No. 6
Continuing Education
Board certification, although important, should not be the only criterion; guidelines should also recognize maintained productive interest, clinical activity, maintenance of knowledge and skills by education and the desire of physicians to change, increase or modify their educational qualifications. Surgical privileges should be examined during hospital surveys for audit or accreditation. SOSSUS1 thinks that a necessary condition for monitoring and controlling surgical residency positions and Board certification rates is the strict limitation of hospital privileges for the performance of major surgical operations. Without this control at the level of practice monitoring or control of the number in training becomes meaningless. The SOSSUS1 report emphasizes that the public's acceptance of stricter hospital credentialling imposes on surgeons an obligation to establish proof of continuing education and continued physical and intellectual fitness by examinatlion, local board review or recertification. SOSSUS' stipulates that there are three components in the improvement of manpower standards for surgery in the United States. These three must be strengthened and maintained as a combined program since they are mutually reinforcing: 1) continuous monitoring and control of residency output and Board certification rates 2) stricter hospital credentialling 3) periodic reassessment of fitness, performance and competence. It is often alleged that there is a nonuniform distribution of surgical services by location and by surgical specialty. The bulk of the surgical manpower data in the SOSSUS' report is concerned with the distribution of surgical specialties. SOSSUS' finds that aside from the expected greater concentration in urban than in rural areas surgeons are remarkably evenly distributed throughout the country-apparently more evenly than are other medical specialists. Despite a relative abundance of surgeons (per hundred thousand) in the northeast, middle Atlantic, northwest and Pacific coast
477
regions, the remainder of the country is not underserved and the regional discrepancies are not large as compared to other medical specialties. Throughout the country there are approximately forty surgeons per one hundred thousand in the cities and twenty per cent per one hundred thousand in the rural areas. SOSSUS1 finds the distribution of surgeons to be more closely correlated with availability of hospital beds than with any other single factor. The mean for the country, based on the average for the states, is 15 hospital beds per surgeon, the urban figure being lower ( 1) and the rural figure higher (25). Since many of the diseases treated by surgeons demand large and complex facilities, a non-uniform distribution of services cannot be equated with substandard care, provided access and transportation are adequate. In general the SOSSUS1 data show the distribution of the most numerous surgical specialists (Board certified) namely general surgeons, obstetrician-gynecologists and orthopedists by state, census district and city to be remarkably even. In both the distribution of surgeons and the relationships among the various surgical specialties it is clear that the free system of career choice and location for practice has served rather well. To quote Francis Moore, "While there are some regional inequities, and one might consider some of the specialties over populated, the overall distribution of surgeons would be very difficult to improve by forceable constraint, obligatory service or penalties for failure to follow legal directions.' Currently, and possibly not for long, medical licensure is adjudicated by the state. The certification of surgical and other medical specialty competence by examination after completion of graduate education is done by the American Boards-in the voluntary or private sector. Accreditation of medical schools and hospitals is done by voluntary agencies. Residency programs are reviewed by voluntary residency review committees and these committees' actions are approved or disapproved by the Liaison Committee on Graduate Medical Education
478
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
-a voluntary group with representation from the AMA, AHA, AAMC, ABMS and the CMSS (Council of Medical Specialty Societies). Above the LCGME in this hierarchy is the Coordinating Council on Medical Education (CCME) established in 1972-73 with similar representation and sponsorship by the great voluntary organizations. The CCME is designed to serve as a supervisory body concerned with policy matters and accreditation of all levels of medical education. Continuing education is abundantly available throughout the country to physicians and surgeons through our university and hospital postgraduate programs, and our local, regional and national organizations such as the National Medical Association and the American College of Surgeons. However, ladies and gentlemen, this voluntary system of ours is under fire from all sides-the heaviest bombardment comes from the banks of the Potomac. Let me briefly list some of the facts. First of all this year the Macy Commission2 published its study of problems of paramount medical concern, touching on the changing supply and distribution of physicians, primary care, graduate medical education, continuing education and many other problems reviewed by the SOSSUS' study. Taken together these issues raised the question of whether there existed an organization in the voluntary sector that could conduct continuing analyses of these problems and recommend corrective solutions. The Macy Commission2 consensus was "no". The Commission recommends the establishment of a new National Commission on Medical Education, Manpower and Services which would coordinate the efforts of other functioning organizations including federal agencies, into a "meaningful national policy in medical education, manpower and medical services". My personal bias opposes the need for such a commission and my concern is that it would become organized, funded and controlled by the federal bureaucracy. In this regard as of June, 1976 the Department
NOVEMBER, 1976
of Health, Education, and Welfare has published the proposal for credentialing health manpower which includes a national system for certification, national standards, federal reimbursement for health care services limited to those with licensure in states with federal standards, proficiency examinations, relicensure and recertification. This proposal ends as follows, "the subcommittee urges that additional support be given to the development of more sophisticated approaches to continued competence which ultimately can be tied into a mandatory recertification or relicensure requirement". As most of you know, voluntary re-examination and recertification is already being offered to diplomates of several boards including, I believe, the American Board of Internal Medicine. The American Board of Surgery will begin its voluntary recertification program in 1980. Literally thousands of surgeons in the last few years have taken, voluntarily, the self-assessment examinations, SESSAP I and II, offered by the American College of Surgeons. I believe American surgeons prefer the word "voluntary" to the bureaucrat's "mandatory". The Senate has passed S 3239,5 the Health Manpower Act of 1976, under the sponsorship of Senator Kennedy. As many as you may know, this Bill proposes to amend the Public Health Service Act to revise and extend the programs under title VII for training in the health professions, to expand the National Health Service Corps and provide scholarships for medical students who will serve in areas of need, and to sponsor training programs in primary care and family medicine. What you may not know is that the current, Senate passed bill has a feature aimed at correction of what Senator Kennedy perceives to be the maldistribution of medical specialists and residency positions by establishing a National Council on Postgraduate Physician Training and 10 regional councils. Mr. Kennedy proposes that after two years of study, the National Council will annually determine the total number of graduate physician training positions and allocate these positions among the various
Vol. 68, No. 6
Continuing Education
specialties and subspecialties. Using a formula as a limit related to a percentage in excess of the number of graduates of medical schools, the National Council will then distribute the total number of residency positions to the ten national regions. The regional councils are to assign the positions allocated to them to the approved programs of graduate medical education in their region. There is much more in this bill, including a proposal to determine the cost of "educating" students as chiropractors in the future. Mr. Kennedy, as usual, is busy at his self-appointed task of regulating physicians and developing more and more federal controls over medical education and medical practice. In closing let me quote from the final paragraph in Dr. Robert Chase's chapter on Government Relations in the SOSSUS report: "Only influence by health professionals can avoid the dangers expressed by Justice Brandeis: 'Experience should teach us to be most on our guard when the government's purposes are beneficent. Men born to freedom are naturally alert to repel invasion of their liberty by evil-minded
479
rulers. The greatest dangers to liberty lurk in insidious encroachment by men of zeal, well-meaning but without understanding'."6 LITERATURE CITED
1. Surgery in the United States. A Summary Report of the Study on Surgical Services for the United States. Chairman G. Zuidema. Sponsored jointly by the American College of Surgeons and the American Surgical Association. Ed., R. A. Potter, 1975. 2. Physicians for the Future-Report of the Macy Commission, Chairman D. Corson. Sponsored by the Josiah Macy, Jr. Foundation. New York. 1976. 3. FLEXNER, ABRAHAM. Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching. Boston, D. B. Updyke, the Merrymount Press, 1910. 4. A Proposal for Credentialing Health Manpower. U.S. Department of Health, Education and Welfare, Public Health Service, Health Resources Administration, June, 1976. 5. S 3239, the Health Manpower Act of 1976. Introduced by Senator Kennedy, 94th Congress 2nd Session, April 1, 1976. Senate Report No. 94-887, Congressional Record. 6. Justice Brandeis: quoted in Chapter XII, p. 202 of SOSSUS report (1) .
(Diggs anid Flowers, from page 493)
4. SHOPE, E. S. and C. VORDER BRUEGGE, L. W. DIGGS, F. 0. RAASCH, and F. M. KING. Sudden Death in Unsuspected Sickle Cell Disease. Read at Am. Soc. Clin. Path. Meeting, Boston, Mass., April 15, 1971. 5. News from the Bench and Examining Room: Sickling Suspected in Football Death. Physician and Sports Medicine, p. 21, October, 1974. 6. MURPHY, J. R. Sickle Cell Hemoglobin (Hb AS) in Black Football Players. J.A.M.A.,
225:981-982, 1973. 7. DIGGS, L. W. and R. WALKER. A Solubility Test for Sickle Cell Hemoglobin, 1. Aggregation and Separation of Soluble and In-
soluble Components without Centrifugation. Lab. Med., 4:27-31, 1973. 8. NAUMANN, H. N. and L. W. DIGGS. Screening Reagent for Hemoglobin S (Hb S). J.A.M.A., 227:1262, 1974. 9. DIGGS, L. W. and C. F. AHMANN, and J. BIBB. The Incidence and Significance of the Sickle Cell Trait. Ann. Int. Med., 7:769778, 1933. 10. DIGGs, L. W. and L. BARRERAS, and R. JOYNER. The Test Tube Turbidity Method as a Screening Procedure for the Detection of Sickle Cell Hemoglobin. Memphis and MidSouth Med. J., 44:313-317, 1969.
![[The status of surgical continuing education in Germany].](/assets/img/hold.png)
