Editorial 313
Reflections on the Future of Pre- and Post-Graduate Medical Education in Thoracic Surgery* 1. Hasse
It is the privilege of the president of this United Annua l Conference of the Austrian. German. an d Swiss Societies for Thoracic and Cardiovasc ular Surgery in his opening ad dress to reference and comme morate th eir achievements and to honour their pr otagonists . However this would require a long oratio n. I will instead restr ict my remarks to one single nam e: Professor Georg Wilhelm Rodewald who last year att end ed this meeting as always but sadly died only a few months later at the age of 70 years . He was a founding memb er of the German Society of Thoracic and Cardiovascular Surgery and he was one of her most notable personalities, adding to her general recognition . Thereby he was also one of thos e who layed the foundation for the frat ernal cooperation with the Austrian and the Swiss Societies. He was a man who unlike many national figures in our field earned highest international reputation. However. I am convinced that he would ha ve sup ported our focusing on another objective i. e. reflection upon current problems, or should I say. dilemmas. It is my hop e that in doing this I might stimulate further discussion both insid e and outside our societi es on how to dea l with thos e problems . Besides many oth ers . one of Rodewald's far-sight ed life works was the contro l of quality standards in open heart surgery. A dominating problem at pr esent, in my opin ion, is the state of medicine in our universities and the quality contro l of today's medical educat ion. I specifically refer to the aca demic medical schoo ls because grievances her e become evident earlier and with more blatancy than in oth er medical institutions. Moreover in university hospitals suc h shortcomings are of particular an d possibly disastrous pertinence . German medical schools are exposed to an ongoing and rather unselected affiux of stu dents and are increasingly hamper ed in coping with their task of proper academic teaching and selection of graduat es. Two years ago I read a brilliant sartirical essay by the American philosopher George Boas in the Johns Hopkins Magazin e (1) . The titel was "How to Kill a University" and som e of his recomm endations might be quot ed here to reinforc e my apprehensions: "Physician s have told us of the dangers of obesity. And Aesop has recorded the fate of a frog who burst from over-puffing. Therefore begin by in-
• Presidential Address of the 21st Annual Meeting of the Germa n Society for Thoraci c and Cardiovascular Surgery February 19 -22. 1992. Bonn
creasing the size of your univers ity. By this I mean the size of your stu dent body and of your administ ration. not of your faculty .. . When you have a un iversity where everyone is engaged in administratio n, either actively or ostensibly, it is like an army in which everyone is an officer ... Unfor tunately universities give aid and comfort to the individual both in wor ks of art and in human behav iour. They encourage discussion , for the good humanist is likely to believe that he may be wrong. Hence to kill a university you must eliminate the humanistic departments ." Transferred to th e medical faculty one could formulate: Eliminate th e humanistic idea of a universal intellectual and compassiona te attitud e in the medical occupation, supp ort the increasing techno cra cy. Some of these suggestions already seem to be reality. The numb er of stud ents starting in medicin e according to an announcement of the "Wissenschaftsrat" (science advisor y council) in 1988 was 19 per 100000 population and by far the highest in th e world and still increasing. Even cautious suggestions of this council to limit the admission of medical stud ents were neutralized by sentences of German adm inistration courts . The sam e year an articl e was publish ed in "Nature" (2) und er the head line "German un ivers ity: an education that takes a lifetime" explaining that a German student is considerably older when finishing the last university exami natio ns compared to a British or French stude nt. Leaving schoo l at the age of about 20 years, and with 6 to 8 years being the duration of aca demic education often after several years of admissio n delay. a life span is occupied which could be one of the most prosperous and creative ones in an individua l life. The conse quences ar e alread y alarmingly per ceptib le. We see many graduat es in our clinics who ar e no longer young but still rather inexperienced doctors. Shortcomings in their pra ctical abilities and deficient medical knowledge, despit e longterm studi es. would actuall y require special endeavours for their continued postgraduate education . However the reality is quite different. As so called C1 limited-employm ent officials (Zeitbeamte) they are bound to a jungle of organizational pressures and they th emselves become a part in this administrative machin ery instead. after all, a participant in th e teaching of th e pr esent stud ent generation. Insufficient salaries for the AiP (doctor in her/his first year an d a half after graduation) and low ones ther eafter favour the registration of overtim e claims with complicated forms (Fig. 1) and adh erance to regulations
Thora c. cardiovasc. Surgeon 40 (1992) 313 - 315
Received for Publication: Aug ust 23. 1992
© Georg Thieme Verlag Stuttgart· New York
Downloaded by: University of British Columbia. Copyrighted material.
Department of Thoracic Sur ger y. University Hospi tal. Univers ity of Fr eiburg. Germ an y
Thorae. eardiovase. Surgeon 40 (1992)
J. Hasse
unparalleled in an y oth er country, a proc ess that is closely watched by union officials. Undoubtedly these conditions are compromising both the motivation and the development of skills and knowl edge mor e than in an y other academi c profession. Nobody shou ld be surprised when the German University hosp ital no longer attracts the ambitious and exceptionally ab le graduates but is left with the representatives of the average. Ther e is a clear risk and actual tend en cy that the elite will turn to top institutions outsid e the universities and even outside this country where a high standard of performance is appreciat ed in the way of both the delegation of responsibility and of appropriate remun eration. This trend impos es on surgical clinics mor e than on oth er specia lties when a growing community of C1 officials, obliged to 38 wor king hours per week and a legal maximum of 10 hours of paid overt ime per week would be entitled to annual vacation and holidays in the range of at least three months. Surg ery will and in fact alr ead y does suffer from these conditions. It becom es increasingly difficult to pr eserve an efficient sequen ce of activities in spit e of rep eated interruption of the information chain. No other discipline will be affected to such an extent, since surgery has th e obligatio n to pass on clinical experience, know ledge of pathophysiology, and training of manual skills. This obligation can hardly be fullfilled if, while ma intainin g constant rates of operative pro cedures , a n ever growing number of aspirants are to become qua lified surgeons.
.................
The field of thorac ic and cardiovasc ular surge ry is in a som ewhat mor e favourab le position due to the demand for surgi cal tr eatm ent keepin g pace fairly closely with the expansion in personnel. These adv antages should be nur tur ed and used. One would hop e that the new ru les of postgraduate education will not only be conceived in an appropriate way, but will also come into power timely enough to avoid fruitless period s of delayed accomplishment of one's individual opera tion list. It is also hoped that our field ther eby retains or regain s the ability to educate dynamic and , physically as well as psychologically, resilient doctors who are motivated towa rds a univer sal and devoted tr eatment of pati ent s. Thoracic and cardiovascular surgery could develop a base function that would pro vide an import ant service to all surgical disciplines by offering an optional opportunity not only to tra in basic man ual skills but mor eover to collect profound clinical experiences in the pa thoph ysiology of the cardio-respiratory and oth er vital systems . I have the impression that in man y young colleagues the competence of comprehensive jud gement of a pati ent's situation atrophies because they lack confidence in their own know ledge and abilities and , furthermore, the impetus to consolidate it of their own initiative. Supp osedly th e seeds of such an attitude have alrea dy been planted in the contemporary structur es of medical schools, wh er e students ' expectations of comfortab le, enter ta ining, and well pr epared lessons are met. Unfortunately, a compensating
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Reflections on the Future of Pre- and Post-Graduate Medical Education in Thoracic Surgery* 1. Hasse
It is the privilege of the president of this United Annua l Conference of the Austrian. German. an d Swiss Societies for Thoracic and Cardiovasc ular Surgery in his opening ad dress to reference and comme morate th eir achievements and to honour their pr otagonists . However this would require a long oratio n. I will instead restr ict my remarks to one single nam e: Professor Georg Wilhelm Rodewald who last year att end ed this meeting as always but sadly died only a few months later at the age of 70 years . He was a founding memb er of the German Society of Thoracic and Cardiovascular Surgery and he was one of her most notable personalities, adding to her general recognition . Thereby he was also one of thos e who layed the foundation for the frat ernal cooperation with the Austrian and the Swiss Societies. He was a man who unlike many national figures in our field earned highest international reputation. However. I am convinced that he would ha ve sup ported our focusing on another objective i. e. reflection upon current problems, or should I say. dilemmas. It is my hop e that in doing this I might stimulate further discussion both insid e and outside our societi es on how to dea l with thos e problems . Besides many oth ers . one of Rodewald's far-sight ed life works was the contro l of quality standards in open heart surgery. A dominating problem at pr esent, in my opin ion, is the state of medicine in our universities and the quality contro l of today's medical educat ion. I specifically refer to the aca demic medical schoo ls because grievances her e become evident earlier and with more blatancy than in oth er medical institutions. Moreover in university hospitals suc h shortcomings are of particular an d possibly disastrous pertinence . German medical schools are exposed to an ongoing and rather unselected affiux of stu dents and are increasingly hamper ed in coping with their task of proper academic teaching and selection of graduat es. Two years ago I read a brilliant sartirical essay by the American philosopher George Boas in the Johns Hopkins Magazin e (1) . The titel was "How to Kill a University" and som e of his recomm endations might be quot ed here to reinforc e my apprehensions: "Physician s have told us of the dangers of obesity. And Aesop has recorded the fate of a frog who burst from over-puffing. Therefore begin by in-
• Presidential Address of the 21st Annual Meeting of the Germa n Society for Thoraci c and Cardiovascular Surgery February 19 -22. 1992. Bonn
creasing the size of your univers ity. By this I mean the size of your stu dent body and of your administ ration. not of your faculty .. . When you have a un iversity where everyone is engaged in administratio n, either actively or ostensibly, it is like an army in which everyone is an officer ... Unfor tunately universities give aid and comfort to the individual both in wor ks of art and in human behav iour. They encourage discussion , for the good humanist is likely to believe that he may be wrong. Hence to kill a university you must eliminate the humanistic departments ." Transferred to th e medical faculty one could formulate: Eliminate th e humanistic idea of a universal intellectual and compassiona te attitud e in the medical occupation, supp ort the increasing techno cra cy. Some of these suggestions already seem to be reality. The numb er of stud ents starting in medicin e according to an announcement of the "Wissenschaftsrat" (science advisor y council) in 1988 was 19 per 100000 population and by far the highest in th e world and still increasing. Even cautious suggestions of this council to limit the admission of medical stud ents were neutralized by sentences of German adm inistration courts . The sam e year an articl e was publish ed in "Nature" (2) und er the head line "German un ivers ity: an education that takes a lifetime" explaining that a German student is considerably older when finishing the last university exami natio ns compared to a British or French stude nt. Leaving schoo l at the age of about 20 years, and with 6 to 8 years being the duration of aca demic education often after several years of admissio n delay. a life span is occupied which could be one of the most prosperous and creative ones in an individua l life. The conse quences ar e alread y alarmingly per ceptib le. We see many graduat es in our clinics who ar e no longer young but still rather inexperienced doctors. Shortcomings in their pra ctical abilities and deficient medical knowledge, despit e longterm studi es. would actuall y require special endeavours for their continued postgraduate education . However the reality is quite different. As so called C1 limited-employm ent officials (Zeitbeamte) they are bound to a jungle of organizational pressures and they th emselves become a part in this administrative machin ery instead. after all, a participant in th e teaching of th e pr esent stud ent generation. Insufficient salaries for the AiP (doctor in her/his first year an d a half after graduation) and low ones ther eafter favour the registration of overtim e claims with complicated forms (Fig. 1) and adh erance to regulations
Thora c. cardiovasc. Surgeon 40 (1992) 313 - 315
Received for Publication: Aug ust 23. 1992
© Georg Thieme Verlag Stuttgart· New York
Downloaded by: University of British Columbia. Copyrighted material.
Department of Thoracic Sur ger y. University Hospi tal. Univers ity of Fr eiburg. Germ an y
Thorae. eardiovase. Surgeon 40 (1992)
J. Hasse
unparalleled in an y oth er country, a proc ess that is closely watched by union officials. Undoubtedly these conditions are compromising both the motivation and the development of skills and knowl edge mor e than in an y other academi c profession. Nobody shou ld be surprised when the German University hosp ital no longer attracts the ambitious and exceptionally ab le graduates but is left with the representatives of the average. Ther e is a clear risk and actual tend en cy that the elite will turn to top institutions outsid e the universities and even outside this country where a high standard of performance is appreciat ed in the way of both the delegation of responsibility and of appropriate remun eration. This trend impos es on surgical clinics mor e than on oth er specia lties when a growing community of C1 officials, obliged to 38 wor king hours per week and a legal maximum of 10 hours of paid overt ime per week would be entitled to annual vacation and holidays in the range of at least three months. Surg ery will and in fact alr ead y does suffer from these conditions. It becom es increasingly difficult to pr eserve an efficient sequen ce of activities in spit e of rep eated interruption of the information chain. No other discipline will be affected to such an extent, since surgery has th e obligatio n to pass on clinical experience, know ledge of pathophysiology, and training of manual skills. This obligation can hardly be fullfilled if, while ma intainin g constant rates of operative pro cedures , a n ever growing number of aspirants are to become qua lified surgeons.
.................
The field of thorac ic and cardiovasc ular surge ry is in a som ewhat mor e favourab le position due to the demand for surgi cal tr eatm ent keepin g pace fairly closely with the expansion in personnel. These adv antages should be nur tur ed and used. One would hop e that the new ru les of postgraduate education will not only be conceived in an appropriate way, but will also come into power timely enough to avoid fruitless period s of delayed accomplishment of one's individual opera tion list. It is also hoped that our field ther eby retains or regain s the ability to educate dynamic and , physically as well as psychologically, resilient doctors who are motivated towa rds a univer sal and devoted tr eatment of pati ent s. Thoracic and cardiovascular surgery could develop a base function that would pro vide an import ant service to all surgical disciplines by offering an optional opportunity not only to tra in basic man ual skills but mor eover to collect profound clinical experiences in the pa thoph ysiology of the cardio-respiratory and oth er vital systems . I have the impression that in man y young colleagues the competence of comprehensive jud gement of a pati ent's situation atrophies because they lack confidence in their own know ledge and abilities and , furthermore, the impetus to consolidate it of their own initiative. Supp osedly th e seeds of such an attitude have alrea dy been planted in the contemporary structur es of medical schools, wh er e students ' expectations of comfortab le, enter ta ining, and well pr epared lessons are met. Unfortunately, a compensating
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1
