ANNALS Vol. 186
OF SURGERY
September 1977
No.
3
Presidential Address: Surgical Competence in
a
Changing World CLAUDE E. WELCH, M.D.
LET ME FIRST EXPRESS my deep appreciation for the honor that you have bestowed on me and for the accompanying privilege that allows the President to present this brief address. Everyone who has been in this position has recognized that formulation of this final statement is one of the most difficult tasks of his career. This is particularly true today when the profession is in turmoil and the public is critical of our efforts. Despite the hazy view ahead the speaker must attempt to open a vista into an unknown future. A simple recapitulation of the exciting events of the past year is inadequate, nor in these days of dynamic change is it sufficient to merely recall or embellish the past. Nevertheless every president seeks inspiration from his predecessors and usually concludes that every topic of interest to surgeons has been analyzed and all speeches couched in such telling phrases that they defy comparison. But this year a combination of events is unique. The tremendous expansion in the number of surgeons in this country and the demands by the public, the government, by lawyers and by the medical profession itself that competence of all physicians be maintained pose problems of enormous magnitude. President Creech said in his address in 1967: "'An era in medicine is drawing to a close, and although it has been a golden period, highlighted by monumental developments in surgery, it is almost over."6 Despite the fact that critics may define the golden age as any time prior to the present, surgeons remain optimists. It is a shock therefore for us to recognize that Presented at the Annual Meeting of the American Surgical Association. Boca Raton, Florida, March 23-25, 1977.
233
From Department of Surgery, Harvard Medical School Boston, Massachusetts
there is a strong popular movement that tends to negate the values of medicine and attacks the efforts of physicians and surgeons alike. Witness these developments: Depletion of funds available for basic research despite the extraordinary accomplishments in the past decade. Credit should be given to the President's Biomedical Research Panel on which many members of this Association served as consultants.14 Due to their efforts it is possible that this deficit may be ameliorated. The enormous increase in malpractice suits, and no ready answers to the problem of professional liability."5 A rash of gloom and doom books and articles on the purported counterproductivity of medicine and the implication that improvement in the length and quality of human life has been accomplished in spite of medicine rather than because of it.10 An attack on the fundamentals of licensure by advocates who would abolish all requirements and allow equal access to the public by such cults as faith healers and naturopaths.4 Allegations of "unnecessary surgery" despite lack of solid supporting data. Among the numerous provisions of Public Law 94484, the imposition by the government of admission policies on medical schools. The medical profession rails at the injustice of these complaints. However, the task today is not to diagnose or to describe in more detail these cur-
234
WELCH
rently unhappy aspects of medicine and surgery, but to consider therapeutic measures that may be employed to restore the medical profession to its proper position. Nevertheless it is important to recognize in rebuttal that though the present surgical age may not be golden, it clearly has substantial merits. Compare the few magnificent surgeons trained by Halsted with the great numbers of well-qualified individuals available throughout the country today. Surgical benefits are more easily available to the nation than they were even a decade ago. However, this abundance of surgeons and facilities has created new problems such as overutilization, but more important, questions of the competence of the profession have been raised. A brief historical note may illustrate the shift of emphasis placed upon the competence of a few individuals in the past to the large number of surgeons who are required to meet the present demands of the nation. Every one of you who reads the Transactions of this Association from the year of its foundation in 1880 will recognize men who appeared in the wings as candidates for membership, who then were acknowledged as the elite as they moved across the stage of surgery, and finally faded into memory. Some were modest, expert practitioners of the art. Others were obstreperous giants whose visions or audacity influenced many lives. Careers of young surgeons, and of many in this audience, have been molded by their personal examples. Who can forget Bevan who served as a fearless chairman of the Council on Medical Education of the A.M.A. from 1918 to 1937 and implemented the Flexner report? Who can forget Graham, an architect of the American Board of Surgery, who perceived the necessity for the dispersal of excellent surgical care throughout the country? Who could forget a demonstration of flawless technique by Pemberton as he easily performed 19 thyroidectomies in the Mayo Clinic in a single morning? Who could forget the aphorisms of my chief Arthur Allen whose uncanny judgment never has been equaled? Who can forget Churchill's piercing questions such as: "Is a palliative operation designed to palliate the patient or the surgeon?" Who could forget Alton Ochsner exuding flames in the bullpen in the Charity Hospital? Who can forget our honored members Lester Dragstedt, Robert Gross, and Owen Wangensteen, the last recipient of the A. S. A. Medallion for Scientific Achievement, who, by his introduction of Fundamental Forums into the program of the American College of Surgeons, fostered an innovation of tremendous importance that united the young and old and led to a rapid rapprochement of academe with clinical surgeons? The history of surgery could be written as a compilation of the contributions of individuals; but
Ann. Surg. * September 1977
today very few surgeons have more than momentary glimpses of such giants. Precepts disappear. Teaching is impersonal. Personalities are replaced by algorithims and computers. A decade ago it was assumed that the competence of a surgeon was guaranteed by his training, by Board certification, and by membership in the American College of Surgeons or an appropriate specialty organization. The issue before us today is, simply are these qualifications sufficient? And if they are sufficient, why is the public so ungenerous as to continue to produce a rash of malpractice suits? We must regain the confidence of an increasingly vocal public that maintains along with many of the profession that there must be methods by which continuing rather than one-time competence may be assured. The greater the number of surgeons, the greater is the necessity that self-renewal of the profession be maintained. Continuing competence depends on each individual, but must be supplemented by the efforts of the profession, by government regulation, or by a combination of the two. To evaluate each individual's performance the favorite methods that have emerged are the use of peer review, of formal examination, or of evidence of continuing medical education. Professional efforts to maintain competence include each of these methods. Peer review mechanisms are numerous. They include such diverse features as qualifications for membership in specialty societies, delineation of hospital privileges according to an individual's competence, and audits of performance; in many of these activities the Joint Commission on Accreditation of Hospitals plays an important role. Unfortunately staffs of many hospitals have not yet accepted their responsibilities and must exert far greater efforts than they have in the past. Recertification by Boards may include peer evaluation; this is planned by the American Board of Surgery. Formal examination almost surely will be the method chosen by the Specialty Boards as a basis for recertification just as they have been used for certification in the past. All 22 Specialty Boards have started to implement either voluntary or mandatory recertification. Evidence of continuing medical education is required for membership in 16 state medical societies although the procedures are not fully implemented in many of them5'9 (Alabama, Arizona, California, Florida, Kansas, Kentucky, Maine, Massachusetts, Minnesota, Montana, New Jersey, New York, North Carolina, Oregon, Pennsylvania and Vermont.) Seven specialty organizations now require continuing medical education for membership.
Vol. 1869No. 3
PRESIDENTIAL ADDRESS
The influence of government is exerted by its power of licensure. However, impatience of the public and the government with the sluggish development of changes initiated by the profession is evidenced by laws that require reregistration and, as a condition, either specify continuing medical education or give powers to the state boards of registration to demand it if they so desire; such laws had been passed in 15 states by August 1, 1976. (In Alaska, Arizona, California, Colorado, Illinois, Kansas, Michigan, and Oregon, the Board of Registration is required by law to establish CME as a requirement for reregistration. In Kentucky, Maryland, Minnesota, Nebraska, New Mexico and Utah, the Board of Registration is authorized but not required by law to require CME for reregistration.) The importance of this trend is shown by the fact that by February 1977 the number of states with such requirements according to Hirsh had risen from 15 to 33.9 Prospective legislation in the Congress also would require specialty recertification as well. A solution to this problem cannot reside either solely with the profession or with the government. It must depend upon the delicate interplay of the government, as an agent of the public, with the profession. Professional standards review organizations have been established as a cooperative venture, but their effect still is not clear. Essentially there are two ways in which the profession may exert influence upon the government. In the past, an adversary approach has been by far the more popular. An effective equalizer in democracies has been for every pressure group to loudly proclaim its own needs and desires. Happily, ultimately, a just accommodation of views often is obtained. This method, popularly ascribed by the public to such groups as labor unions, or to "organized medicine," has had the support of the great majority of physicians. However, too vigorous efforts can become counterproductive, and antagonize the public, which ultimately will prove to be the arbiter in such disputes. The other way is to recognize the needs of the public and by constructive influence on governmental affairs to mold the desires of the profession with the welfare of the community. Ultimately if the public is well informed the needs of the people and the goals of the profession should merge. What do we as surgeons list as our important objectives? First and foremost is to maintain medicine as a learned profession in distinction to a trade union. This duty requires not only a regular increase in knowledge by basic and clinical research, and education of health workers, but also beyond the care of individual patients, implies a genuine responsibility to
235
the public. Former Chief Justice Brandeis has stated that "a profession is an occupation for which the necessary preliminary training is intellectual in character, involving knowledge, and to some extent, learning, as distinguished from mere skill. It is an occupation which is pursued largely for others and not merely for one's self. It is an occupation in which the amount of financial return is not the accepted measure of success."3 Subsidiary objectives of current interest to this Association include: 1) constant renewal of the members of the profession by a continued inflow of wellqualified medical students and by continuing education for the profession; 2) the supply of an adequate number of well-trained surgeons with proper specialty distribution; 3) the performance of surgical procedures by well-qualified surgeons; 4) the elimination of incompetents and malfeasors; and 5) the resolution of professional liability problems. The Association has spoken vigorously in support of many of these principles in the past few years. The SOSSUS Report and the statement on professional liability published in December 1976 are outstanding examples.1'18 To gain these objectives, however, influence upon the government must be exerted at all levels. It is recognized that high level communication has been and will continue to be maintained by the American Surgical Association in such ways that have been described by our recent Presidents and by the efforts of our Committees on Governmental Affairs and on Issues. It also must be recognized that slavish acquiescence with every pronouncement from Washington is impossible and undesirable; checks and balances and opposing opinions occur at every level, and even in the same legislative acts. However, this morning I propose to descend to the lower end of the scale to a level in which cooperation between the state, the law, the judiciary and the medical profession must be firmly established and where many nitty gritty decisions must be made. I speak of the state boards of registration in medicine, unsung workers in the vineyard. It must be recognized that state boards of registration have in the past been regarded with some disdain by the public and by the profession itself. However, in many jurisdictions they recently have acquired new powers that are capable of exerting an enormous influence on the public and on the profession. This influence is emerging at this moment. Its extent can be appraised only in a very tentative fashion, though it is apparent that if a federal board shotild be established its influence would be instant and enormous. It will be the main purpose of this discussion to assess the potential of such governmental boards and
236
WELCH
to decide if they can, by their actions, lead to the same objectives as those of the surgical profession. As Chairman of the completely reorganized Board of Registration and Discipline in Medicine for the Commonwealth of Massachusetts, I wish to bring to you some evidence by which you may judge the effects that such a Board may produce. A critical assessment of the value of Boards of Registration will include a list of weaknesses and advantages. The defects will be considered first. When reregistration became mandatory in several states and a generous fee was required, the profession attacked the law because it was considered to be a form of unjust taxation. Large funds now are paid into many state treasuries for licenses and reregistration, and only a portion is returned to the Boards for their use to fulfill their statutory duties. Furthermore, many physicians believe that whenever further statutes or regulations are established more chains are forged on the medical profession. Boards can be established and originally be constituted of able persons who are replaced later by political appointees so that the bright promise exerted at the outset may be completely lost within the course of a few years. Finally, since the boards must pursue each serious case with detailed investigations and long legal processes, the question may be raised as to whether or not boards can function rapidly and effectively enough to actually improve the practice of
medicine. Despite these objections it has been extremely heartening to note the support of the A.M.A. and of many state medical and national specialty societies of actions designed to strengthen the power of the state Boards. The increase in malpractice claims has been a strong stimulus to this development, for a few incompetent physicians can besmirch the entire profession. Voluntary societies recognize that the most serious action that can be taken against a member is to dismiss him from membership in that organization. Even this procedure can lead to expensive legal fees so that there is little desire to carry it out with any frequency. Furthermore, malfeasors often do not belong to a state medical society or specialty society. It is because of these defects that state medical societies and specialty societies must look to stronger bodies to investigate and if necessary punish offenders. Governmental groups such as state Boards of Registration are available for this purpose. In Massachusetts due to strong pressure not only from the public, but from the Massachusetts Medical Society, a statute was passed in July 1975 relative to medical malpractice. There were five important features in this statute as follows: A new Board of Registration and Discipline in
Ann. Surg. e September 1977
Medicine was established consisting of five physicians and two representatives of the public. They carry out reregistration of physicians every two years. The new Board was given the usual power to discipline those doctors who were guilty of offenses against laws of Commonwealth relating to the practice of medicine but in addition the duty to identify and rectify substandard levels of practice and a broad power to "adopt rules and regulations governing the practice of medicine in order to promote the public health, welfare and safety." A joint underwriting association was established to insure all physicians who could not obtain malpractice insurance elsewhere. Medical tribunals, consisting of a supreme court judge, a lawyer and a physician were established to hear all claims of malpractice. Nuisance suits are discouraged by the requirement that, if the tribunal has decided that the complaint has no merit a $2,000 bond must be posted before a case proceeds to trial. The bond is forfeited if the plaintiff pursues the claim through the usual tort system and loses. Changes in the tort law were made involving elimination of ad damnum statements (which specify an amount sought by the plaintiff in a suit, always a highly inflated figure.) Furthermore, restriction of the limits of filing claims to three years from the date of occurrence is specified except for children under age six, where a claim is allowed until the ninth birthday. A special permanent commission-on the study of malpractice was formed. It will be noted that many of these changes were specified in the report of malpractice prepared by our Committee on Issues. This carefully worded statement included 1) methods to deal with incompetent or negligent physicians, 2) approved screening panels, 3) suggested three methods of settlement of meritorious claims (by the tort system, by binding arbitration, or by settlement from a list of compensable events in the absence of negligence), 4) approved a revision of the tort system, 5) suggested alternatives in insurance writing (including an elective no-fault policy), and 6) advocated permanent state commissions on malpractice. Three features of the Massachusetts statutes will be described in detail. The Board of Registration and Discipline
What has been accomplished by our Board? In the first place, 1,594 new full licenses to practice medicine and surgery were issued in the Commonwealth in 1976. Reregistration was necessary for 14,247 M.D.s and D.O.s In order to maintain good public relations and to
PRESIDENTIAL ADDRESS
Vol. 186oNo. 3
improve the quality of medicine, careful attention must be paid to all complaints that are received by the Board: there were 253 in the first year. Over half of them have been closed and the others are under active investigation. These complaints range all the way from comparatively trivial matters to very serious implications of immoral acts; the majority, however, deal with some aspect of medical practice in which the patient has been dissatisfied with the doctor. In a 12-month period two licenses were revoked and two other resignations under pressure have occurred. Meanwhile, actions against 25 other physicians are in progress. The Joint Underwriting Association (JUA)
Eight thousand-eight hundred-sixty-nine physicians and surgeons and 115 hospitals with 20,696 beds became members of the JUA in the first year. Physicians paid $27.8 million in premiums to November 30, 1976. Rates for general surgeons for $1 million per claim and $3 million total were set on a claims made policy of $1,359 and an occurrence policy of $3,981. If these fees do not cover losses an assessment on all physicians in the state is authorized. Only $135,000 was paid out during this time in claims. It is obvious from this figure that the nest egg established in this one year has created far more than enough money in interest to pay all the claims that have so far been adjudicated. Medical Tribunals
The medical tribunals are composed of a superior court judge, a lawyer and a physician and are set up to hear every malpractice claim. Judge McLaughlin, the former State Supreme Justice, believes that the law will stand all constitutional tests, that it is working, and that it can be even strengthened further by requiring a $5,000 bond rather than a smaller one. From January 1 to November 24, 1976, 277 cases of medical malpractice were filed with the medical tribunals. Twenty-four were dismissed prior to the tribunal, 141 are awaiting action, and 112 have been heard. In the 112 instances a verdict for the plaintiff was returned in 42, so that the cases could proceed to trial. A verdict for the defendant was returned in 63; in these a bond was posted for trial in 15, and 38 of them were dismissed. Thus in approximately 60o of the cases the tribunals decided that there was no negligence involved and over a third of the cases that have come before them have been dismissed.2 As one surveys this record it is apparent that some of the objectives of the profession are, in a modest
237
way, being accomplished. However, removal of incompetents or malfeasors is a woefully slow process because of the long legal struggles that must occur in each case. The Board therefore has established a number of rules and regulations and has initiated other procedures to inform the public. All meetings of the Board are open to anyone who wishes to appear. Rules and regulations are established after public hearings; although none of them yet have been tested in a court of law there seems to be little doubt that the decisions of the Board will be supported. The most important rules and regulations now being established by the Board provide for 1) the yearly requirement that 50 hours of continuing medical education be established as a condition for reregistration, 2) the development of a new type of license that restricts the type of practice, and 3) the construction of an accurate data base that can serve as a directory for health manpower. Improvements in the standards of medical practice could be aided by rules and regulations that are under consideration, to restrict the practice of acupuncture, by regulations concerning physicians' assistants,* and by statements concerning the performance of specialized procedures such as open heart surgery. It is apparent that these measures could have an immense influence in raising the standards of the practice of medicine. I should like to discuss each of them in detail but the time will not permit. Therefore I will concentrate on those that I regard of the highest priority. They are continuing medical education as a condition of reregistration, restriction of type of practice, and construction of an accurate data base for medical manpower. Continuing Medical Education (CME)
Arguments in favor of CME are the same as for any type of education; be it elementary school, high school, college, medical school or residency. They include 1) education is a life-long process; 2) it is impossible to use knowledge that one does not have; 3) even insofar as facts are known, there is an important decrease in the retention of such facts over a period of years; 4) much medical knowledge has been developed since the last formal education of a doctor; 5) physicians can choose programs that fit their special needs; 6) CME is controlled by physicians; 7) CME is more palatable to the profession than repeated formal examinations; 8) CME may be more objective than peer review; and 9) the amount of time spent in CME is easy to document (though admittedly, documentation of its value is difficult except where a specific course is directed toward the acquisition of a new skill or technique or a new
238
WELCH
piece of information is imparted that may be immediately useful). The arguments against continuing medical education are more numerous but in general are concerned with methodology. They may be listed as follows. 1) CME in many instances has deteriorated into bonanzas for travel agents. The motive of education must be rescued. 2) Despite a plethora of courses no one of them may be tailored to the individual doctor's needs. 3) Education preferably should be given on the spot of action so that the lessons will not be lost. 4) Time for CME cannot be expended by the busy community doctor except to the detriment of his patients. 5) Manual skills of surgeons cannot be corrected by blackboard courses. 6) Estimates of the education acquired by tests that are given to see if practice patterns have been improved by such courses essentially all show very little change with reversal back to former habits within a few months. 7) Courses vary greatly in their content and value. Good teachers are rare though speakers are innumerable. 8) Surgeons learn in different ways. Courses, audiovisual aids, voluntary examinations, staff conferences and individual study all are valuable. How can they be combined in a tidy package to fit all takers? 9) CME may even be dangerous for some surgeons, for it will lead them to believe that they can carry out procedures they see illustrated at medical meetings but cannot be considered to be safe or indicated in their own locations. 10) CME is extremely expensive. Thus Miller has estimated that the cost to the medical profession now is approximately $2 billion yearly.11 It also is certain that the whole field of continuing medical education currently is in disarray; hopefully order will be established by the Liaison Committee on Continuing Medical Education in the near future. It thus is clear that absolute proof of the value of CME is hard to substantiate. Yet, after an annual meeting of the American College of Surgeons what person can escape without some visual memory of the method by which a difficult technical problem may be handled or can fail to remember some statements from the platform that change his concepts of proper care? Despite these negative comments and lack of absolute proof there is a deeply instilled belief among educators that CME confers great benefits. The American College of Surgeons has developed the greatest postgraduate programs in the world and has expended hundreds of thousands of dollars for voluntary selfassessment examinations. The A.M.A. has invested heavily in the accreditation of postgraduate courses and in the development of the Physicians Recognition Award, that has been accepted by all states who have a compulsory requirement of CME.
Ann. Surg. M September 1977
A recent conference organized by Egdahl and supported by the Johnson Foundation brought all of these arguments into focus and ended with the comment by the chairman and although the value of CME remains somewhat equivocal in the minds of many observers, the great majority accept it on faith.7 On the other hand, evidence of CME represents the blandest and most modest attempt by which continuing competence can be judged. In other words, it is obviously not a process that is certain to reinvigorate the knowledge of the profession, nor is there any proof that the possession of the facts will lead to wisdom, to manual skills, to a blameless life, or in short to a superb, morally unimpeachable profession. If the standards of the profession are to be maintained, added methods are necessary. Restrictions of Type of Practice
Every person who obtains a full license to practice in this country is empowered to act as "physician and surgeon." Further restrictions of licenses have raised many thorny problems in the past and in general never have been faced squarely by the medical profession. For example, it is accepted as a truism that a good surgeon must first be a good physician; on the other hand, it has never been proposed that a good physician must first be a good surgeon. While it is not difficult in individual instances by processes of peer review, especially in hospital environments, to determine the type of practice that a doctor is able to conduct, it is an almost impossible task to establish legal definitions that may be placed in statutes. For example, how does one accurately define the practice of medicine, the practice of surgery, or the practice of any of the surgical specialties? This is a quagmire and it is impossible to handle by definition. The only logical way in which it can be done is by peer review of individuals at the local level. Essentially this means that if the privileges of a person are limited in any one hospital because of lack of training or ability, such restrictions should be applicable to all the hospitals in which he practices. Mandatory reporting of such restrictions to the Board of Registration will indicate the magnitude of this problem; at the present time it is completely unestimated and may vary from trivial to major importance. There have been instances, however, in which a surgeon deprived of privileges in one hospital merely has moved to a neighboring town to carry out the same procedures under less stringent supervision. Such deliquencies could be detected by PSROs but their mechanisms are not yet established and they would have no legal right to control the activities of such surgeons under any circumstances. Another type of restriction of license concerns dip-
Vol. 186oNo. 3
PRESIDENTIAL ADDRESS
lomates of certain specialty boards. For example, in Massachusetts any person who passes the FLEX examination with the appropriate grade is given a license to practice medicine and surgery. Such designation in the minds of many in this audience amounts to a sort of a hunting license that is restrained mainly by the fears of high malpractice premiums. Furthermore a full license may be obtained by anyone who is a diplomate of a specialty board recognized by the A.M.A. even though he has not passed the FLEX examination. Therefore, for example, someone trained in such a specialty as pathology or anesthesiology would be empowered to practice medicine and surgery in any way that he deems fit. It would seem appropriate that individuals who have been certified by the specialty boards but have not passed FLEX examinations should be allowed to practice only in their specialty. The concept of restriction of license is one that to my knowledge has not been employed by any of the state boards and is one that clearly could be contested on legal grounds. However, it is suggested in PL 94484, and if such specifications are established for the benefit of the public, it is unlikely that any appeal on the basis of constitutionality would be effective. These methods are of great importance to surgeons who practice in hospitals approved by the JCAH. There are many other loopholes, however. For example, in a small hospital that has only one or two persons in each department, peer review is very difficult to carry out. Although nearly all hospitals with over 100 beds are inspected by the JCAH, many small hospitals are not accredited. Peer review in these areas may be extremely poor (Schlicke reported in 1973, that of 7,123 hospitals in the United States only 5,075 (71%) were currently accredited).16 Finally, the physician who maintains only an office practice will be difficult to observe or to evaluate. Construction of an Accurate Data Base for Medical Manpower The extreme difficulties that attend an estimation of medical manpower are obvious to everyone in this audience. At the present time the best available data are furnished by the A.M.A. Interestingly enough the A.M.A. publishes two data sets, one in the "Directory of Approved Residencies,"and the other in "Distribution of Physicians in the U.S." Both of them suffer from the fact that the material is acquired by voluntary submission, the first chiefly from the directors of surgical services and the other from questionnaires returned by individuals. It is very important to note that the figures in these two publications are not compatible. Such differences have served to accentuate the unfortunate differences of opinion that have taken place in the past year over the SOSSUS data.
239
It is certain that if application for licensure and requirements for reregistration must include data specified by state licensing boards, such figures will be highly reliable. Since reregistration is required every two years a reasonable estimate of current manpower always should be available. By including such questions in the data sets such as designation as an intern or resident, the year of graduation, name of medical school, details of practice (location, type, etc.) accurate figures can be obtained. Furthermore, by requiring statements concerning specialty board certification, it is possible to separate the truly qualified specialists from the self-designated specialists. Heretofore in all collected data "specialists" have included both selfdesignated and Specialty Board certified individuals; such a method tends to muddy a distinction that is very important for the public welfare. These data, made available to the public, should promote the selection of well qualified physicians by patients. But even here, collection of such data and their submission to the public will be influenced by the Privacy Act of 1974 which requires acquiescence of each individual if any "personal" information is released. Either voluntary submission of data must be secured, or the definition of the term "personal" in rules and regulations will be critical. Finally, let us turn to a few major trends in the practice of medicine and surgery in order to assess the relationship of licensing boards. The recent report of the Carnegie Council on Policy Studies in Higher Education indicates that there will be an oversupply of doctors in the U.S.A. by 1980.13 Primary care physicians will become much more numerous in the near future. Our Study on Surgical Services for the United States (SOSSUS) has suggested that too many persons are performing surgical procedures and that surgical residencies must be reduced in number. These forces combined with high rates of malpractice insurance will diminish the number of individuals performing surgery in this country. The far-reaching effects of PL94-484, which states flatly that there is today an adequate supply of physicians in this country, should reduce the number of foreign-born surgeons admitted to training programs. However, there are opposing forces. Many residency slots formerly filled by foreign medical graduates potentially could be filled by U.S. citizens who had been refused admission to medical schools in this country but had entered schools abroad. Furthermore, unless our laws are changed there will be continual movement back into any surgical vacuum which is created so that there will be a never-ending fringe of individuals who are relatively incompetent. This number conceivably may be increased by surgeons who originally are certified by specialty boards but refuse to
240
WELCH
accept recertification, by general practitioners attracted into the domain of surgery by a resurrected rotating internship, or even by such nebulous entities as "physicians extenders" which now are appearing on the political horizon. Clearly, if surgical procedures are to be performed by qualified surgeons, Boards of Registration ultimately can play a critical role. In summary, the surgical profession for an indefinite time must be shored up from within and without. Competent practitioners of surgery must be provided. In this paper it is emphasized that the greatest impetus must come from the profession itself but that additional momentum can be achieved by cooperation with other agencies and professions. State Boards of Registration serve as prime examples. And if Boards of Registration are in this way symbols of a cooperative future, what is the portent? If they are successful in their duties the possibility of a federal bureau of registration is enhanced. Alternatively, if they fail, calls for federal registration will become even louder than they are today. Such prospects conjure pictures of stricter control of the entire medical profession and are frightening to the A.M.A., to most specialty societies and the Federation of State Boards. Yet this prospect must be faced in the very near future and as it develops, as it surely will, it must receive careful attention from this Association. To achieve our ends we must maintain vigilance at all levels of government. For even a profession that is superbly competent can be eroded by rules and regulations. President Muller stressed the need for the American Surgical Association to assume leadership so that all of the profession can speak with a unified voice.12 President Hardy cannily observed that the American College of Surgeons has both talent and muscle, but that the A.M.A. has access to the votes.8 Collaboration by the American Surgical Association at these upper levels is essential. However, in addition it is necessary to emphasize the other end of the scale and the overwhelming importance of the support of an informed public if we are to attain our ends. It was a combination of professional and public effort that led to statutory changes in Massachusetts just as it has been in many other jurisdictions. As conflicts continue in Washington, if we demonstrate public accountability, and if we convince our citizens that we are concerned with the interests of
Ann. Surg. * September 1977
the public, we acquire a weapon of enormous power that will serve us well in the maintenance of a competent profession of surgeons. President Scott has urged this Association to become an organization of political activists.17 Perhaps this report will serve as a personal testament, proving that each one of us has an individual as well as a collective responsibility. Let us all keep our fingers in the dike. References 1. American Surgical Association Statement of Professional Liability, September, 1976. N. Engl. J. Med. 295:1292, 1976. 2. Annual Report of the Special Commission on Medical Malpractice, Commonwealth of Massachusetts, December 29, 1976. 3. Brandeis, L. B.: Chap. 1. Business as a Profession. Quoted in Strauss, M. B.: Familiar Medical Quotations. Boston, Little, Brown and Co., 1968. 4. Carlson, R. J.: Alternative Legislative Strategies for Licensure: Licensure and Health, In Egdahl, R. H. and Gertman, P. M. (eds): Quality Assurance in Health Care. Germantown, Aspen Systems Corp., 1976, pp. 243-268. 5. Continuing Medical Education. J.A.M.A. 236:2993, 1976. 6. Creech, O., Jr.: Presidential Address: The Surgical Residency Revisited. Ann. Surg., 166:303, 1967. 7. Egdahl, R. H., and Gertman, P. M. (eds): Quality Assurance in Health Care. Germantown, Aspen Systems Corp., 1976. 8. Hardy, J. D.: American Surgery- 1976. Ann. Surg., 184:245, 1976. 9. Hirsh, H. L.: Not Until Death do you Part. J. Legal Med. 5:25, 1977. 10. Illych, I.: Medical Nemesis. New York Pantheon Books, 1976. 11. Miller, L. A.: The Current Investment in Continuing Medical Education, In Egdahl, R. H., Gertman, P. M., Taft, C. H., and Giller, D. R. (eds.): Continuing Medical Education and Qualtiy Health Care: What is the Link? Report of a Conference on Continuing Medical Education and Quality Health Care, Boston, June 11- 12, 1976, New York, Springer-Verlag, 1976. 12. Muller, W. H., Jr.: Presidential Address: United We Stand. Ann. Surg., 182:177, 1975. 13. Progress and Problems in Medical and Dental Education. Federal Support Versus Federal Control. A Report of the Carnegie Council on Policy Studies in Higher Education. San Francisco, Jossey-Bass Publishers, 1976. 14. Report of the President's Bicmedical Research Panel. U. S. Department of Health, Education, and Welfare, DHEW Publication No. (OS) 76-500, 1976. 15. Report of the Secretary's Commission on Medical Malpractice. Department of Health, Education, and Welfare, DHEW Publication No. (OS) 73-88, 1973. 16. Schlicke, C. P.: American Surgery's Noblest Experiment. Arch. Surg., 106:379, 1973. 17. Scott, H. W., Jr.: Presidential Address: Professional Freedom and Governmental Control. Ann. Surg., 180:377, 1974. 18. Surgery in the United States, A Summary Report of the Study on Surgical Services in the United States. American College of Surgeons and The American Surgical Association, 1975.
OF SURGERY
September 1977
No.
3
Presidential Address: Surgical Competence in
a
Changing World CLAUDE E. WELCH, M.D.
LET ME FIRST EXPRESS my deep appreciation for the honor that you have bestowed on me and for the accompanying privilege that allows the President to present this brief address. Everyone who has been in this position has recognized that formulation of this final statement is one of the most difficult tasks of his career. This is particularly true today when the profession is in turmoil and the public is critical of our efforts. Despite the hazy view ahead the speaker must attempt to open a vista into an unknown future. A simple recapitulation of the exciting events of the past year is inadequate, nor in these days of dynamic change is it sufficient to merely recall or embellish the past. Nevertheless every president seeks inspiration from his predecessors and usually concludes that every topic of interest to surgeons has been analyzed and all speeches couched in such telling phrases that they defy comparison. But this year a combination of events is unique. The tremendous expansion in the number of surgeons in this country and the demands by the public, the government, by lawyers and by the medical profession itself that competence of all physicians be maintained pose problems of enormous magnitude. President Creech said in his address in 1967: "'An era in medicine is drawing to a close, and although it has been a golden period, highlighted by monumental developments in surgery, it is almost over."6 Despite the fact that critics may define the golden age as any time prior to the present, surgeons remain optimists. It is a shock therefore for us to recognize that Presented at the Annual Meeting of the American Surgical Association. Boca Raton, Florida, March 23-25, 1977.
233
From Department of Surgery, Harvard Medical School Boston, Massachusetts
there is a strong popular movement that tends to negate the values of medicine and attacks the efforts of physicians and surgeons alike. Witness these developments: Depletion of funds available for basic research despite the extraordinary accomplishments in the past decade. Credit should be given to the President's Biomedical Research Panel on which many members of this Association served as consultants.14 Due to their efforts it is possible that this deficit may be ameliorated. The enormous increase in malpractice suits, and no ready answers to the problem of professional liability."5 A rash of gloom and doom books and articles on the purported counterproductivity of medicine and the implication that improvement in the length and quality of human life has been accomplished in spite of medicine rather than because of it.10 An attack on the fundamentals of licensure by advocates who would abolish all requirements and allow equal access to the public by such cults as faith healers and naturopaths.4 Allegations of "unnecessary surgery" despite lack of solid supporting data. Among the numerous provisions of Public Law 94484, the imposition by the government of admission policies on medical schools. The medical profession rails at the injustice of these complaints. However, the task today is not to diagnose or to describe in more detail these cur-
234
WELCH
rently unhappy aspects of medicine and surgery, but to consider therapeutic measures that may be employed to restore the medical profession to its proper position. Nevertheless it is important to recognize in rebuttal that though the present surgical age may not be golden, it clearly has substantial merits. Compare the few magnificent surgeons trained by Halsted with the great numbers of well-qualified individuals available throughout the country today. Surgical benefits are more easily available to the nation than they were even a decade ago. However, this abundance of surgeons and facilities has created new problems such as overutilization, but more important, questions of the competence of the profession have been raised. A brief historical note may illustrate the shift of emphasis placed upon the competence of a few individuals in the past to the large number of surgeons who are required to meet the present demands of the nation. Every one of you who reads the Transactions of this Association from the year of its foundation in 1880 will recognize men who appeared in the wings as candidates for membership, who then were acknowledged as the elite as they moved across the stage of surgery, and finally faded into memory. Some were modest, expert practitioners of the art. Others were obstreperous giants whose visions or audacity influenced many lives. Careers of young surgeons, and of many in this audience, have been molded by their personal examples. Who can forget Bevan who served as a fearless chairman of the Council on Medical Education of the A.M.A. from 1918 to 1937 and implemented the Flexner report? Who can forget Graham, an architect of the American Board of Surgery, who perceived the necessity for the dispersal of excellent surgical care throughout the country? Who could forget a demonstration of flawless technique by Pemberton as he easily performed 19 thyroidectomies in the Mayo Clinic in a single morning? Who could forget the aphorisms of my chief Arthur Allen whose uncanny judgment never has been equaled? Who can forget Churchill's piercing questions such as: "Is a palliative operation designed to palliate the patient or the surgeon?" Who could forget Alton Ochsner exuding flames in the bullpen in the Charity Hospital? Who can forget our honored members Lester Dragstedt, Robert Gross, and Owen Wangensteen, the last recipient of the A. S. A. Medallion for Scientific Achievement, who, by his introduction of Fundamental Forums into the program of the American College of Surgeons, fostered an innovation of tremendous importance that united the young and old and led to a rapid rapprochement of academe with clinical surgeons? The history of surgery could be written as a compilation of the contributions of individuals; but
Ann. Surg. * September 1977
today very few surgeons have more than momentary glimpses of such giants. Precepts disappear. Teaching is impersonal. Personalities are replaced by algorithims and computers. A decade ago it was assumed that the competence of a surgeon was guaranteed by his training, by Board certification, and by membership in the American College of Surgeons or an appropriate specialty organization. The issue before us today is, simply are these qualifications sufficient? And if they are sufficient, why is the public so ungenerous as to continue to produce a rash of malpractice suits? We must regain the confidence of an increasingly vocal public that maintains along with many of the profession that there must be methods by which continuing rather than one-time competence may be assured. The greater the number of surgeons, the greater is the necessity that self-renewal of the profession be maintained. Continuing competence depends on each individual, but must be supplemented by the efforts of the profession, by government regulation, or by a combination of the two. To evaluate each individual's performance the favorite methods that have emerged are the use of peer review, of formal examination, or of evidence of continuing medical education. Professional efforts to maintain competence include each of these methods. Peer review mechanisms are numerous. They include such diverse features as qualifications for membership in specialty societies, delineation of hospital privileges according to an individual's competence, and audits of performance; in many of these activities the Joint Commission on Accreditation of Hospitals plays an important role. Unfortunately staffs of many hospitals have not yet accepted their responsibilities and must exert far greater efforts than they have in the past. Recertification by Boards may include peer evaluation; this is planned by the American Board of Surgery. Formal examination almost surely will be the method chosen by the Specialty Boards as a basis for recertification just as they have been used for certification in the past. All 22 Specialty Boards have started to implement either voluntary or mandatory recertification. Evidence of continuing medical education is required for membership in 16 state medical societies although the procedures are not fully implemented in many of them5'9 (Alabama, Arizona, California, Florida, Kansas, Kentucky, Maine, Massachusetts, Minnesota, Montana, New Jersey, New York, North Carolina, Oregon, Pennsylvania and Vermont.) Seven specialty organizations now require continuing medical education for membership.
Vol. 1869No. 3
PRESIDENTIAL ADDRESS
The influence of government is exerted by its power of licensure. However, impatience of the public and the government with the sluggish development of changes initiated by the profession is evidenced by laws that require reregistration and, as a condition, either specify continuing medical education or give powers to the state boards of registration to demand it if they so desire; such laws had been passed in 15 states by August 1, 1976. (In Alaska, Arizona, California, Colorado, Illinois, Kansas, Michigan, and Oregon, the Board of Registration is required by law to establish CME as a requirement for reregistration. In Kentucky, Maryland, Minnesota, Nebraska, New Mexico and Utah, the Board of Registration is authorized but not required by law to require CME for reregistration.) The importance of this trend is shown by the fact that by February 1977 the number of states with such requirements according to Hirsh had risen from 15 to 33.9 Prospective legislation in the Congress also would require specialty recertification as well. A solution to this problem cannot reside either solely with the profession or with the government. It must depend upon the delicate interplay of the government, as an agent of the public, with the profession. Professional standards review organizations have been established as a cooperative venture, but their effect still is not clear. Essentially there are two ways in which the profession may exert influence upon the government. In the past, an adversary approach has been by far the more popular. An effective equalizer in democracies has been for every pressure group to loudly proclaim its own needs and desires. Happily, ultimately, a just accommodation of views often is obtained. This method, popularly ascribed by the public to such groups as labor unions, or to "organized medicine," has had the support of the great majority of physicians. However, too vigorous efforts can become counterproductive, and antagonize the public, which ultimately will prove to be the arbiter in such disputes. The other way is to recognize the needs of the public and by constructive influence on governmental affairs to mold the desires of the profession with the welfare of the community. Ultimately if the public is well informed the needs of the people and the goals of the profession should merge. What do we as surgeons list as our important objectives? First and foremost is to maintain medicine as a learned profession in distinction to a trade union. This duty requires not only a regular increase in knowledge by basic and clinical research, and education of health workers, but also beyond the care of individual patients, implies a genuine responsibility to
235
the public. Former Chief Justice Brandeis has stated that "a profession is an occupation for which the necessary preliminary training is intellectual in character, involving knowledge, and to some extent, learning, as distinguished from mere skill. It is an occupation which is pursued largely for others and not merely for one's self. It is an occupation in which the amount of financial return is not the accepted measure of success."3 Subsidiary objectives of current interest to this Association include: 1) constant renewal of the members of the profession by a continued inflow of wellqualified medical students and by continuing education for the profession; 2) the supply of an adequate number of well-trained surgeons with proper specialty distribution; 3) the performance of surgical procedures by well-qualified surgeons; 4) the elimination of incompetents and malfeasors; and 5) the resolution of professional liability problems. The Association has spoken vigorously in support of many of these principles in the past few years. The SOSSUS Report and the statement on professional liability published in December 1976 are outstanding examples.1'18 To gain these objectives, however, influence upon the government must be exerted at all levels. It is recognized that high level communication has been and will continue to be maintained by the American Surgical Association in such ways that have been described by our recent Presidents and by the efforts of our Committees on Governmental Affairs and on Issues. It also must be recognized that slavish acquiescence with every pronouncement from Washington is impossible and undesirable; checks and balances and opposing opinions occur at every level, and even in the same legislative acts. However, this morning I propose to descend to the lower end of the scale to a level in which cooperation between the state, the law, the judiciary and the medical profession must be firmly established and where many nitty gritty decisions must be made. I speak of the state boards of registration in medicine, unsung workers in the vineyard. It must be recognized that state boards of registration have in the past been regarded with some disdain by the public and by the profession itself. However, in many jurisdictions they recently have acquired new powers that are capable of exerting an enormous influence on the public and on the profession. This influence is emerging at this moment. Its extent can be appraised only in a very tentative fashion, though it is apparent that if a federal board shotild be established its influence would be instant and enormous. It will be the main purpose of this discussion to assess the potential of such governmental boards and
236
WELCH
to decide if they can, by their actions, lead to the same objectives as those of the surgical profession. As Chairman of the completely reorganized Board of Registration and Discipline in Medicine for the Commonwealth of Massachusetts, I wish to bring to you some evidence by which you may judge the effects that such a Board may produce. A critical assessment of the value of Boards of Registration will include a list of weaknesses and advantages. The defects will be considered first. When reregistration became mandatory in several states and a generous fee was required, the profession attacked the law because it was considered to be a form of unjust taxation. Large funds now are paid into many state treasuries for licenses and reregistration, and only a portion is returned to the Boards for their use to fulfill their statutory duties. Furthermore, many physicians believe that whenever further statutes or regulations are established more chains are forged on the medical profession. Boards can be established and originally be constituted of able persons who are replaced later by political appointees so that the bright promise exerted at the outset may be completely lost within the course of a few years. Finally, since the boards must pursue each serious case with detailed investigations and long legal processes, the question may be raised as to whether or not boards can function rapidly and effectively enough to actually improve the practice of
medicine. Despite these objections it has been extremely heartening to note the support of the A.M.A. and of many state medical and national specialty societies of actions designed to strengthen the power of the state Boards. The increase in malpractice claims has been a strong stimulus to this development, for a few incompetent physicians can besmirch the entire profession. Voluntary societies recognize that the most serious action that can be taken against a member is to dismiss him from membership in that organization. Even this procedure can lead to expensive legal fees so that there is little desire to carry it out with any frequency. Furthermore, malfeasors often do not belong to a state medical society or specialty society. It is because of these defects that state medical societies and specialty societies must look to stronger bodies to investigate and if necessary punish offenders. Governmental groups such as state Boards of Registration are available for this purpose. In Massachusetts due to strong pressure not only from the public, but from the Massachusetts Medical Society, a statute was passed in July 1975 relative to medical malpractice. There were five important features in this statute as follows: A new Board of Registration and Discipline in
Ann. Surg. e September 1977
Medicine was established consisting of five physicians and two representatives of the public. They carry out reregistration of physicians every two years. The new Board was given the usual power to discipline those doctors who were guilty of offenses against laws of Commonwealth relating to the practice of medicine but in addition the duty to identify and rectify substandard levels of practice and a broad power to "adopt rules and regulations governing the practice of medicine in order to promote the public health, welfare and safety." A joint underwriting association was established to insure all physicians who could not obtain malpractice insurance elsewhere. Medical tribunals, consisting of a supreme court judge, a lawyer and a physician were established to hear all claims of malpractice. Nuisance suits are discouraged by the requirement that, if the tribunal has decided that the complaint has no merit a $2,000 bond must be posted before a case proceeds to trial. The bond is forfeited if the plaintiff pursues the claim through the usual tort system and loses. Changes in the tort law were made involving elimination of ad damnum statements (which specify an amount sought by the plaintiff in a suit, always a highly inflated figure.) Furthermore, restriction of the limits of filing claims to three years from the date of occurrence is specified except for children under age six, where a claim is allowed until the ninth birthday. A special permanent commission-on the study of malpractice was formed. It will be noted that many of these changes were specified in the report of malpractice prepared by our Committee on Issues. This carefully worded statement included 1) methods to deal with incompetent or negligent physicians, 2) approved screening panels, 3) suggested three methods of settlement of meritorious claims (by the tort system, by binding arbitration, or by settlement from a list of compensable events in the absence of negligence), 4) approved a revision of the tort system, 5) suggested alternatives in insurance writing (including an elective no-fault policy), and 6) advocated permanent state commissions on malpractice. Three features of the Massachusetts statutes will be described in detail. The Board of Registration and Discipline
What has been accomplished by our Board? In the first place, 1,594 new full licenses to practice medicine and surgery were issued in the Commonwealth in 1976. Reregistration was necessary for 14,247 M.D.s and D.O.s In order to maintain good public relations and to
PRESIDENTIAL ADDRESS
Vol. 186oNo. 3
improve the quality of medicine, careful attention must be paid to all complaints that are received by the Board: there were 253 in the first year. Over half of them have been closed and the others are under active investigation. These complaints range all the way from comparatively trivial matters to very serious implications of immoral acts; the majority, however, deal with some aspect of medical practice in which the patient has been dissatisfied with the doctor. In a 12-month period two licenses were revoked and two other resignations under pressure have occurred. Meanwhile, actions against 25 other physicians are in progress. The Joint Underwriting Association (JUA)
Eight thousand-eight hundred-sixty-nine physicians and surgeons and 115 hospitals with 20,696 beds became members of the JUA in the first year. Physicians paid $27.8 million in premiums to November 30, 1976. Rates for general surgeons for $1 million per claim and $3 million total were set on a claims made policy of $1,359 and an occurrence policy of $3,981. If these fees do not cover losses an assessment on all physicians in the state is authorized. Only $135,000 was paid out during this time in claims. It is obvious from this figure that the nest egg established in this one year has created far more than enough money in interest to pay all the claims that have so far been adjudicated. Medical Tribunals
The medical tribunals are composed of a superior court judge, a lawyer and a physician and are set up to hear every malpractice claim. Judge McLaughlin, the former State Supreme Justice, believes that the law will stand all constitutional tests, that it is working, and that it can be even strengthened further by requiring a $5,000 bond rather than a smaller one. From January 1 to November 24, 1976, 277 cases of medical malpractice were filed with the medical tribunals. Twenty-four were dismissed prior to the tribunal, 141 are awaiting action, and 112 have been heard. In the 112 instances a verdict for the plaintiff was returned in 42, so that the cases could proceed to trial. A verdict for the defendant was returned in 63; in these a bond was posted for trial in 15, and 38 of them were dismissed. Thus in approximately 60o of the cases the tribunals decided that there was no negligence involved and over a third of the cases that have come before them have been dismissed.2 As one surveys this record it is apparent that some of the objectives of the profession are, in a modest
237
way, being accomplished. However, removal of incompetents or malfeasors is a woefully slow process because of the long legal struggles that must occur in each case. The Board therefore has established a number of rules and regulations and has initiated other procedures to inform the public. All meetings of the Board are open to anyone who wishes to appear. Rules and regulations are established after public hearings; although none of them yet have been tested in a court of law there seems to be little doubt that the decisions of the Board will be supported. The most important rules and regulations now being established by the Board provide for 1) the yearly requirement that 50 hours of continuing medical education be established as a condition for reregistration, 2) the development of a new type of license that restricts the type of practice, and 3) the construction of an accurate data base that can serve as a directory for health manpower. Improvements in the standards of medical practice could be aided by rules and regulations that are under consideration, to restrict the practice of acupuncture, by regulations concerning physicians' assistants,* and by statements concerning the performance of specialized procedures such as open heart surgery. It is apparent that these measures could have an immense influence in raising the standards of the practice of medicine. I should like to discuss each of them in detail but the time will not permit. Therefore I will concentrate on those that I regard of the highest priority. They are continuing medical education as a condition of reregistration, restriction of type of practice, and construction of an accurate data base for medical manpower. Continuing Medical Education (CME)
Arguments in favor of CME are the same as for any type of education; be it elementary school, high school, college, medical school or residency. They include 1) education is a life-long process; 2) it is impossible to use knowledge that one does not have; 3) even insofar as facts are known, there is an important decrease in the retention of such facts over a period of years; 4) much medical knowledge has been developed since the last formal education of a doctor; 5) physicians can choose programs that fit their special needs; 6) CME is controlled by physicians; 7) CME is more palatable to the profession than repeated formal examinations; 8) CME may be more objective than peer review; and 9) the amount of time spent in CME is easy to document (though admittedly, documentation of its value is difficult except where a specific course is directed toward the acquisition of a new skill or technique or a new
238
WELCH
piece of information is imparted that may be immediately useful). The arguments against continuing medical education are more numerous but in general are concerned with methodology. They may be listed as follows. 1) CME in many instances has deteriorated into bonanzas for travel agents. The motive of education must be rescued. 2) Despite a plethora of courses no one of them may be tailored to the individual doctor's needs. 3) Education preferably should be given on the spot of action so that the lessons will not be lost. 4) Time for CME cannot be expended by the busy community doctor except to the detriment of his patients. 5) Manual skills of surgeons cannot be corrected by blackboard courses. 6) Estimates of the education acquired by tests that are given to see if practice patterns have been improved by such courses essentially all show very little change with reversal back to former habits within a few months. 7) Courses vary greatly in their content and value. Good teachers are rare though speakers are innumerable. 8) Surgeons learn in different ways. Courses, audiovisual aids, voluntary examinations, staff conferences and individual study all are valuable. How can they be combined in a tidy package to fit all takers? 9) CME may even be dangerous for some surgeons, for it will lead them to believe that they can carry out procedures they see illustrated at medical meetings but cannot be considered to be safe or indicated in their own locations. 10) CME is extremely expensive. Thus Miller has estimated that the cost to the medical profession now is approximately $2 billion yearly.11 It also is certain that the whole field of continuing medical education currently is in disarray; hopefully order will be established by the Liaison Committee on Continuing Medical Education in the near future. It thus is clear that absolute proof of the value of CME is hard to substantiate. Yet, after an annual meeting of the American College of Surgeons what person can escape without some visual memory of the method by which a difficult technical problem may be handled or can fail to remember some statements from the platform that change his concepts of proper care? Despite these negative comments and lack of absolute proof there is a deeply instilled belief among educators that CME confers great benefits. The American College of Surgeons has developed the greatest postgraduate programs in the world and has expended hundreds of thousands of dollars for voluntary selfassessment examinations. The A.M.A. has invested heavily in the accreditation of postgraduate courses and in the development of the Physicians Recognition Award, that has been accepted by all states who have a compulsory requirement of CME.
Ann. Surg. M September 1977
A recent conference organized by Egdahl and supported by the Johnson Foundation brought all of these arguments into focus and ended with the comment by the chairman and although the value of CME remains somewhat equivocal in the minds of many observers, the great majority accept it on faith.7 On the other hand, evidence of CME represents the blandest and most modest attempt by which continuing competence can be judged. In other words, it is obviously not a process that is certain to reinvigorate the knowledge of the profession, nor is there any proof that the possession of the facts will lead to wisdom, to manual skills, to a blameless life, or in short to a superb, morally unimpeachable profession. If the standards of the profession are to be maintained, added methods are necessary. Restrictions of Type of Practice
Every person who obtains a full license to practice in this country is empowered to act as "physician and surgeon." Further restrictions of licenses have raised many thorny problems in the past and in general never have been faced squarely by the medical profession. For example, it is accepted as a truism that a good surgeon must first be a good physician; on the other hand, it has never been proposed that a good physician must first be a good surgeon. While it is not difficult in individual instances by processes of peer review, especially in hospital environments, to determine the type of practice that a doctor is able to conduct, it is an almost impossible task to establish legal definitions that may be placed in statutes. For example, how does one accurately define the practice of medicine, the practice of surgery, or the practice of any of the surgical specialties? This is a quagmire and it is impossible to handle by definition. The only logical way in which it can be done is by peer review of individuals at the local level. Essentially this means that if the privileges of a person are limited in any one hospital because of lack of training or ability, such restrictions should be applicable to all the hospitals in which he practices. Mandatory reporting of such restrictions to the Board of Registration will indicate the magnitude of this problem; at the present time it is completely unestimated and may vary from trivial to major importance. There have been instances, however, in which a surgeon deprived of privileges in one hospital merely has moved to a neighboring town to carry out the same procedures under less stringent supervision. Such deliquencies could be detected by PSROs but their mechanisms are not yet established and they would have no legal right to control the activities of such surgeons under any circumstances. Another type of restriction of license concerns dip-
Vol. 186oNo. 3
PRESIDENTIAL ADDRESS
lomates of certain specialty boards. For example, in Massachusetts any person who passes the FLEX examination with the appropriate grade is given a license to practice medicine and surgery. Such designation in the minds of many in this audience amounts to a sort of a hunting license that is restrained mainly by the fears of high malpractice premiums. Furthermore a full license may be obtained by anyone who is a diplomate of a specialty board recognized by the A.M.A. even though he has not passed the FLEX examination. Therefore, for example, someone trained in such a specialty as pathology or anesthesiology would be empowered to practice medicine and surgery in any way that he deems fit. It would seem appropriate that individuals who have been certified by the specialty boards but have not passed FLEX examinations should be allowed to practice only in their specialty. The concept of restriction of license is one that to my knowledge has not been employed by any of the state boards and is one that clearly could be contested on legal grounds. However, it is suggested in PL 94484, and if such specifications are established for the benefit of the public, it is unlikely that any appeal on the basis of constitutionality would be effective. These methods are of great importance to surgeons who practice in hospitals approved by the JCAH. There are many other loopholes, however. For example, in a small hospital that has only one or two persons in each department, peer review is very difficult to carry out. Although nearly all hospitals with over 100 beds are inspected by the JCAH, many small hospitals are not accredited. Peer review in these areas may be extremely poor (Schlicke reported in 1973, that of 7,123 hospitals in the United States only 5,075 (71%) were currently accredited).16 Finally, the physician who maintains only an office practice will be difficult to observe or to evaluate. Construction of an Accurate Data Base for Medical Manpower The extreme difficulties that attend an estimation of medical manpower are obvious to everyone in this audience. At the present time the best available data are furnished by the A.M.A. Interestingly enough the A.M.A. publishes two data sets, one in the "Directory of Approved Residencies,"and the other in "Distribution of Physicians in the U.S." Both of them suffer from the fact that the material is acquired by voluntary submission, the first chiefly from the directors of surgical services and the other from questionnaires returned by individuals. It is very important to note that the figures in these two publications are not compatible. Such differences have served to accentuate the unfortunate differences of opinion that have taken place in the past year over the SOSSUS data.
239
It is certain that if application for licensure and requirements for reregistration must include data specified by state licensing boards, such figures will be highly reliable. Since reregistration is required every two years a reasonable estimate of current manpower always should be available. By including such questions in the data sets such as designation as an intern or resident, the year of graduation, name of medical school, details of practice (location, type, etc.) accurate figures can be obtained. Furthermore, by requiring statements concerning specialty board certification, it is possible to separate the truly qualified specialists from the self-designated specialists. Heretofore in all collected data "specialists" have included both selfdesignated and Specialty Board certified individuals; such a method tends to muddy a distinction that is very important for the public welfare. These data, made available to the public, should promote the selection of well qualified physicians by patients. But even here, collection of such data and their submission to the public will be influenced by the Privacy Act of 1974 which requires acquiescence of each individual if any "personal" information is released. Either voluntary submission of data must be secured, or the definition of the term "personal" in rules and regulations will be critical. Finally, let us turn to a few major trends in the practice of medicine and surgery in order to assess the relationship of licensing boards. The recent report of the Carnegie Council on Policy Studies in Higher Education indicates that there will be an oversupply of doctors in the U.S.A. by 1980.13 Primary care physicians will become much more numerous in the near future. Our Study on Surgical Services for the United States (SOSSUS) has suggested that too many persons are performing surgical procedures and that surgical residencies must be reduced in number. These forces combined with high rates of malpractice insurance will diminish the number of individuals performing surgery in this country. The far-reaching effects of PL94-484, which states flatly that there is today an adequate supply of physicians in this country, should reduce the number of foreign-born surgeons admitted to training programs. However, there are opposing forces. Many residency slots formerly filled by foreign medical graduates potentially could be filled by U.S. citizens who had been refused admission to medical schools in this country but had entered schools abroad. Furthermore, unless our laws are changed there will be continual movement back into any surgical vacuum which is created so that there will be a never-ending fringe of individuals who are relatively incompetent. This number conceivably may be increased by surgeons who originally are certified by specialty boards but refuse to
240
WELCH
accept recertification, by general practitioners attracted into the domain of surgery by a resurrected rotating internship, or even by such nebulous entities as "physicians extenders" which now are appearing on the political horizon. Clearly, if surgical procedures are to be performed by qualified surgeons, Boards of Registration ultimately can play a critical role. In summary, the surgical profession for an indefinite time must be shored up from within and without. Competent practitioners of surgery must be provided. In this paper it is emphasized that the greatest impetus must come from the profession itself but that additional momentum can be achieved by cooperation with other agencies and professions. State Boards of Registration serve as prime examples. And if Boards of Registration are in this way symbols of a cooperative future, what is the portent? If they are successful in their duties the possibility of a federal bureau of registration is enhanced. Alternatively, if they fail, calls for federal registration will become even louder than they are today. Such prospects conjure pictures of stricter control of the entire medical profession and are frightening to the A.M.A., to most specialty societies and the Federation of State Boards. Yet this prospect must be faced in the very near future and as it develops, as it surely will, it must receive careful attention from this Association. To achieve our ends we must maintain vigilance at all levels of government. For even a profession that is superbly competent can be eroded by rules and regulations. President Muller stressed the need for the American Surgical Association to assume leadership so that all of the profession can speak with a unified voice.12 President Hardy cannily observed that the American College of Surgeons has both talent and muscle, but that the A.M.A. has access to the votes.8 Collaboration by the American Surgical Association at these upper levels is essential. However, in addition it is necessary to emphasize the other end of the scale and the overwhelming importance of the support of an informed public if we are to attain our ends. It was a combination of professional and public effort that led to statutory changes in Massachusetts just as it has been in many other jurisdictions. As conflicts continue in Washington, if we demonstrate public accountability, and if we convince our citizens that we are concerned with the interests of
Ann. Surg. * September 1977
the public, we acquire a weapon of enormous power that will serve us well in the maintenance of a competent profession of surgeons. President Scott has urged this Association to become an organization of political activists.17 Perhaps this report will serve as a personal testament, proving that each one of us has an individual as well as a collective responsibility. Let us all keep our fingers in the dike. References 1. American Surgical Association Statement of Professional Liability, September, 1976. N. Engl. J. Med. 295:1292, 1976. 2. Annual Report of the Special Commission on Medical Malpractice, Commonwealth of Massachusetts, December 29, 1976. 3. Brandeis, L. B.: Chap. 1. Business as a Profession. Quoted in Strauss, M. B.: Familiar Medical Quotations. Boston, Little, Brown and Co., 1968. 4. Carlson, R. J.: Alternative Legislative Strategies for Licensure: Licensure and Health, In Egdahl, R. H. and Gertman, P. M. (eds): Quality Assurance in Health Care. Germantown, Aspen Systems Corp., 1976, pp. 243-268. 5. Continuing Medical Education. J.A.M.A. 236:2993, 1976. 6. Creech, O., Jr.: Presidential Address: The Surgical Residency Revisited. Ann. Surg., 166:303, 1967. 7. Egdahl, R. H., and Gertman, P. M. (eds): Quality Assurance in Health Care. Germantown, Aspen Systems Corp., 1976. 8. Hardy, J. D.: American Surgery- 1976. Ann. Surg., 184:245, 1976. 9. Hirsh, H. L.: Not Until Death do you Part. J. Legal Med. 5:25, 1977. 10. Illych, I.: Medical Nemesis. New York Pantheon Books, 1976. 11. Miller, L. A.: The Current Investment in Continuing Medical Education, In Egdahl, R. H., Gertman, P. M., Taft, C. H., and Giller, D. R. (eds.): Continuing Medical Education and Qualtiy Health Care: What is the Link? Report of a Conference on Continuing Medical Education and Quality Health Care, Boston, June 11- 12, 1976, New York, Springer-Verlag, 1976. 12. Muller, W. H., Jr.: Presidential Address: United We Stand. Ann. Surg., 182:177, 1975. 13. Progress and Problems in Medical and Dental Education. Federal Support Versus Federal Control. A Report of the Carnegie Council on Policy Studies in Higher Education. San Francisco, Jossey-Bass Publishers, 1976. 14. Report of the President's Bicmedical Research Panel. U. S. Department of Health, Education, and Welfare, DHEW Publication No. (OS) 76-500, 1976. 15. Report of the Secretary's Commission on Medical Malpractice. Department of Health, Education, and Welfare, DHEW Publication No. (OS) 73-88, 1973. 16. Schlicke, C. P.: American Surgery's Noblest Experiment. Arch. Surg., 106:379, 1973. 17. Scott, H. W., Jr.: Presidential Address: Professional Freedom and Governmental Control. Ann. Surg., 180:377, 1974. 18. Surgery in the United States, A Summary Report of the Study on Surgical Services in the United States. American College of Surgeons and The American Surgical Association, 1975.
