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THE SURGICAL INTERNSHIP AND RESIDENCY* FRANCIS D. MOORE, M.D. Elliot Carr Cutler Professor of Surgery Harvard Medical School Boston, Massachussetts
T HE central ethical problem in the surgical internship and residency is this: Can a young person-a raw neophyte-learn to operate skillfully, mercifully, and wisely without jeopardizing the welfare of the patient? Clearly, two moral values conflict: the moral imperative to teach a young generation and the moral imperative that each patient have the most skillful person available to operate upon him. Several subsidiary matters have received a lot of recent publicity, such as what does one tell the patient when a learner is at the wheel or the knife? Can a learner be at the scalpel while the teacher is really at the controls? Is this some sort of ghost operation or ghastly proxy fraud? Who gets paid for what and for doing which to whom? But all those questions, despite television and the headlines, are merely footnotes to the central problem: protecting the welfare of the patient while the resident is being taught a highly skilled act. Although this central problem is a major one, it is neither numerically nor statistically so prominent as often supposed. There are about 2,000 residency programs in the 7,500 hospitals in this country. They include about 40% of the beds; it is estimated that about 20% of the major surgical operations performed in the United States involve teacher-learner encounters. The rest, for better or worse, represent a classical one-on-one, doctor-patient contact, sometimes less satisfactory or less expert than those in which learning occurs under the guidance of an expert. But this relation of teacher to learner and its relation to the unspoken patient contract is not unique to surgery. It exists in medicine, pediatrics, psychiatry, and in such diagnostic work as radiology. The need for respon*Presented in a panel, Ethical Concerns in Clinical Teaching, as a part of a Symposium on Ethical Concerns in Modern Medical Education held by the Committee on Medical Education of the New York Academy of Medicine October 13, 1977. Address for reprint requests: Department of Surgery, Harvard Medical School, 10 Shattuck Street, Boston, MA 02115.
Bull. N.Y. Acad. Med.
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sibility and candor in these nonsurgical fields is generally underestimated. It is my impression that responsibility on many teaching medical services is much more glibly passed down with much less serious supervision than is habitual and routine in surgery. But surgery is selected for this program, I am sure, because it has a high public profile. It is a prototype, a model, that throws the whole problem into high relief. Because surgery involves a special manual and learned skill, it must be learned by doing. One cannot learn to play the piano by going to concerts, even if they are given by Horowitz, Rachmaninoff, or Van Cliburn. One must practice, and one must perform alone. The major points I shall consider are, first, the various historic solutions for the teaching enigma in surgery. Second, the numbers game: credentials, the number of surgeons to be trained, and the entry of government through the Federal Trade Commission to harass ethical standard-setting in medicine. Third, the double-standard versus the single-standard system of conducting teaching hospitals. Finally, I shall propose what I think is the most acceptable solution. Historic solutions offered for this enigma offer much amusing and instructive medical history. The first and most ancient solution to the tranining enigma is what might be called the "little-to-big" system whereby the self-taught general practitioner progresses to become a general surgeon. This is on-the-job learning, and every patient is at hazard. We may laugh at this, but it is the ancient American tradition of the frontier. It is part of our open society. That the American Medical Association generally has taken a negative view of advanced residencies has its grassroots origin in this typically American concept, that anyone can do anything, and all one has to do is try. The British had a different viewpoint throughout their history. When King James IV gave that charter to the Royal College of Surgeons at Edinburgh, he said in effect: "You do it, you're the people to do it and to teach others." But he also said a very interesting thing in that first charter. He said, "No one else will be allowed to do it." The Royal Charter gave the surgeons the responsibility for both practicing and teaching and with it the monopoly. The British government favored monopoly while ours detests it and wishes to open surgical practice to all. Ethnic and national traditions sometimes are in striking contrast. The second historic method has been apprenticeship. It had certain virtues. The old Mayo Clinic fellowships in surgery were just that. Many Vol. 54, No. 7, July-August 1978
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do not realize that the Mayo Clinic training programs in surgery were not approved by the American Boards until very recently. The apprentice relation appeared to stifle individual learning performance, yet many eminent surgeons graduated from the Mayo Clinic system. Now the Mayo Clinic has replaced their old fellowship system by a standard surgical residency, involving graduated, personal responsibility and acceptance for training. Despite all this historical development, there is a general tendency to scorn an apprenticeship system, because it basically involves a single learner working with a single, older person over a prolonged time, with little opportunity for that learner to see other ways of doing things. Another historic method used on both sides of the Atlantic Ocean was the didactic, postgraduate course. This involved lots of lectures and didactic sessions, including illustrated lectures of surgical operations, and was followed by a lot of examinations, but the student had very little or no contact with patients. If he passed all this he was given a diploma. Reduced to absurdity, this was the British F.R.C.S. system in 1925. People arrived from the Empire, Africa, or India, studied for months or years in London, and finally took an examination. If they passed this examination, they became Fellows of the Royal College, and success was assured back home. But sometimes, even if they failed, they could claim some virtue for having been there and taken the examination several times. The American system, whatever its subsequent faults, was an immediate improvement on this sterile, didactic approach. From Halsted on, it emphasized contact with patients and individual responsibility. Thus we come to the Halstedian, two-standard system based on the ward patient, virtually always black, in the Baltimore of 1895. I was a little shocked to hear Dr. Stanley E. Bradley praise the ward patient as good teaching material because of lesser affluence and privilege. For all the virtues of the Halsted residency, we have come to view this type of segregation of a less privileged population, as elitist and essentially a thing of the past. While we accept a resident's service (under the professor), we have come to view the concentration of welfare cases, often of a special race or minority group, taken care of exclusively by residents and without guidance from the attending staff as very undesirable. That was the double-standard or two-standard system at its peak. Today we often deal with a modification of this that might be called the "limping or cover-up one-and-a-half standard" system. This governs much American graduate teaching today. The patient is not quite sure who Bull. N.Y. Acad. Med.
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is in charge or who is doing what. Neither, often, does the learner. Frequently the teacher has not really planned it out in much detail. The patient may be rich, poor, sophisticated, or not. This represents surgical training in transition. The system seems to work most of the time because of reasonable intelligence on the part of all, reasonable trust and good will on the part of the patient, and reasonable supervision by the teacher. And finally we come to the open, acknowledged, one-standard system of postgraduate education, not only in surgery but in medicine, pediatrics, radiology, pathology, psychiatry, radiotherapy, and all the rest. In the single-standard system, all patients who enter the door of the hospital, the emergency ward, or the outpatient department acknowledge that their care will be managed by a team that basically consists of two individuals, a teacher and a learner although, there may, of course, be others in both roles. The care and responsibility and the actual physical care are shared by both members of the team, always with adequate supervision. In the single-standard system the teacher-learner relation is assumed. Viewing any system of surgical training, we tend to concentrate on the ethical aspects of the operation itself. Perhaps we tend to overemphasize that one aspect. What is the patient's understanding of the nature of the contract regarding the rest of his care? Is the physician's responsibility limited just to the operation? Should we not raise the same questions about "ghost surgery" when we consider who gets up at night to examine the patient's acute abdomen, who writes the intravenous order, who talks to the troubled family over the telephone, who plans the roentgenograms, prescribes the antibiotics, the morphine, or the digitalis? Where did we get the idea that the surgical operation was the only place that involved an important ethical transaction as regards teacher and learner? In the single-standard system all these aspects are openly shared by both, with supervision by the teacher and participation by the learner. It is always a little shocking to visit a teaching hospital in which the older man, the teacher, does the operation from start to finish in an entirely nonsharing mode, only to leave the hospital and go somewhere else or home to bed for the night, leaving 100% responsibility for all other aspects of the patient's care to the learner. This is obviously an unhealthy principle and an unethical situation. In the single-standard system the teacher would have shared the operation with the learner and would have taken a greater part in the subsequent events. Another assumption to be examined is that the learner is always an Vol. 54, No. 7, July-August 1978
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individual with inferior ability. Age and education differ, and the older person should bring experience and possibly greater wisdom, but the younger may bring more vigor, new ideas from more recent exposure to basic sciences, more participation in the interdisciplinary atmosphere of medical school and the first hospital years. That younger person, whom we categorize as the learner, is frequently somewhat of a teacher himself with special skills. He brings far more to the encounter than blundering ignorance. In fact, the older individual will often work more efficiently and effectively in partnership with a younger person. The ideal interphysician contact of two people involved in patient care is an older person working with a younger person. The two generations work well together. The older-younger partnership has been a tradition in medicine since ancient times, and its open acknowledgement is one of the best features of the single-standard system. The word doctor means teacher and recognizes the intrinsic teaching function of any physician in contact with the younger generation. Turning to the "numbers game," consideration of the number of trainees relative to national needs enters our ethical discourse because overexpanded training programs leave physicians with an inadequate practicing base and inadequate experience as residents, while programs that are under-recruited and not large enough to meet national needs fail to meet the moral imperative to teach medicine at the postgraduate level. We will not review detailed numbers of the total number involved in surgical practice and residency training here, except to emphasize that the recently completed National Surgical Study (SOSSUS) demonstrated that the number of board-certified surgeons in this country was probably adequate to do the job and possibly a little more than adequate, that far too many physicians without any credentials for surgical training perform major operations, and, finally, that the residency pipeline of trainees in progress graduates too many people each year. A continued, rather alarming growth in the size of the surgical establishment is in store for the next few years. That study concluded that the one step needed at this time was to reduce the size of the residency-training force in surgery, to provide each learner with better experience in his hospital years, and to send somewhat fewer graduates into the practicing cohort. Such a restriction, whether voluntarily or through some sort of edict, would necessarily involve the assumption by hospital trustees and the public at large that only trained surgeons should carry out major surgery. It Bull. N.Y. Acad. Med.
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is historically interesting that now, in the latter portion of the 20th century, we appreciate the potentially monopolistic overtones of the credentialing system. It is quite wasteful and chaotic to mount an elaborate and carefully monitored training program in a field of medicine if, upon completion, there is no restriction of practice to those who have been through the training. Stated in simple terms, standards of excellence in achievement during the postgraduate years must be accompanied by suitable credentials and supervision at the hospital level to assure the patient that the individual performing the operation has actually completed training. While we are discussing this with relation to surgery, it is important to emphasize that precisely the same relation exists in radiotherapy, in certain aspects of cardiology and psychiatry, and in certain consultant areas of internal medicine. In all areas where the physician carries out acts of mercy that require skills and are hazardous if poorly performed, the public will require the protection of documented credentials of training and achievement. Should not a patient bothered by uterine bleeding somehow be assured of the skill of the person who does that simplest of all gynecological operations, dilatation and curettage? Should she not be assured that her surgeon knows the possible diagnostic components and is supported by a good pathologist and radiologist? This requirement of assurance for the public is not confined to surgery, but is an ethical aspect of postgraduate training handled by advanced licensure in many western European countries. We have no advanced licensure system in the United States. Instead, we have the American Board Examinations. Standards of educational achievement must be set, with documented proof of passage to protect the public. Thus, credentialing is an ethical problem intrinsic to the residency training, and yet, giving an examination and selecting those who pass is, in essence, a form of discrimination. This discriminatory aspect and the potential for monopoly have recently attracted the attention of the government through the Federal Trade Commission (FTC). We can express the hope as members of the public and as tax payers that the FTC will enter this arena with full appreciation that some degree of monopoly and discrimination is intrinsic to any set of standards established to protect the public. The sort of licensure that permits a pilot to fly the Atlantic, even the sort of licensure that lets a plumber or electrician repair one's home, is discriminatory and in a sense monopolistic but absolutely essential to protect the public. Vol. 54, No. 7, July-August 1978
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The question often arises, what is the evidence that the fully trained surgeon is any better, wiser, more honest, or more skillful than others? There is little evidence, and, in fact, it would be very difficult to collect such evidence in any westernized country today. In fact, it is a specious and misleading question. What is the evidence that a 747 pilot can fly the Atlantic Ocean in a large airplane better than one licensed only to fly a Piper cub? Do we have to run a double-blind trial to see how many crashes occur in both hands? Obviously not. The public will insist on an external measure of skill and achievement for those permitted to carry out hazardous acts of public service. The fallibility of examinations is acknowledged. The discriminant aspect of credentialing is evident: some will be more competent than others. Nonetheless, the public expects and deserves some arrangement to document the completion of adequate training. This may seem a long digression in a discussion possibly intended to bear on "ghost surgery." Yet the very existence of residency training and its current appreciation by the public is justified by a postgraduate curriculum, passing examinations, the presentation of credentials to the public, and limitation of that skilled work to those with the credentials. It seems to me that the most appropriate ethical climate for postgraduate residency training in the United States today is the single-standard system. I believe I have discussed it enough to make it clear how it works; it views all the patients within a hospital as cared for by a team in which the older generation (teachers) work in partnership with the younger generation (learners). It appreciates that the younger generation brings a great deal to the welfare of the patient, and that this doctor-student relation is a historic one in medicine, honored in the Hippocratic Oath. Obviously, a host of details cannot be discussed in this short period. The degree of participation of both, the manner in which the patient comes to understand this system, and the matter of discrimination and taste in selection of those components of the care process to be carried out solo by the learner- all these are important details of the single-standard system, and failure to discuss them elaborately today is a product of time constraints rather than failure to appreciate their importance. I should like to mention one aspect, bearing specifically on surgery: the selection of the individual who is actually to perform the act of operation-to wield the scalpel-according to the patient's disease rather than the patient's socioeconomic status or race. In the single-standard Bull. N.Y. Acad. Med.
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system, a patient with a very complicated pulmonary neoplasm, a difficult rectal tumor, an invasive kidney cancer, or a very complex aortoiliac vascular reconstruction is operated upon by the more experienced individual, whether that patient comes from the mansions along the Hudson River, or the lower East Side, whether the skin color be black, white, or yellow, whether the bank account runs into six figures or a deficit. By the same token, the patient with a perfectly straightforward appendicitis, cholelithiasis, thyroid nodule. or carcinoma of the colon is operated upon by the learner, always with the supervision and suitable participation of the teacher, and without reference to socioeconomic or racial factors. This allocation of the manual components of surgery according to the complexity of the patient's disease rather than his social status comes as somewhat of a shock to an older generation raised in the Halstedian system. It also comes as somewhat of a shock to the public. Many individuals with high incomes and elaborate social and educational backgrounds, assume that somehow they will never be touched by an intern, resident, or student. At the same time, many individuals of humble background approach the hospital with the almost certain knowledge that the boss will never come to see them. One of the most appealing aspects of the single-standard system of training is the obliteration of these ancient assumptions. They will not disappear rapidly, and it is going to take a lot of people preaching the message of the single-standard of residency training to bring it to pass. At the beginning of this talk I indicated that surgery is always selected for these discussions because it is such a spectacular example of individual responsibility at the operating table. Yet I cannot emphasize too strongly that the selection of the right dose of insulin or digitalis, the performance of the lumbar puncture in a patient with elevated cerebrospinal fluid pressure, the reading of the roentgenograms in a patient with a peculiar skeletal shadow, and the selection of the treatment port in a patient with a simple, small skin cancer make abundantly clear that ethical standards in postgraduate residency training are not in any sense confined to surgery. We may be up against a problem that forces us to find a way. But if we find that way then that is a way appropriate for other fields of medicine. The single-standard system has many other consequences. The younger and the older join in follow-up, in seeing patients together early and late, in preoperative, preadmission, or postoperative management. It may begin to look like an apprenticeship if the older person and the younger are Vol. 54, No. 7, July-August 1978
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always the same individuals. But as long as they change around, as they do in modem teaching hospitals, then we are dealing with an ethically acceptable and at the same time pedagogically sound residency program. What happens to ghost surgery in all this? In the old days, ghost surgery referred to an itinerant teacher, and now refers to the resident learner. Very few people are aware of this remarkable change in the meaning of the term. Around the turn of the century a general practitioner carrying out a difficult operation often called in a consultant from the big city who came and helped him through it, there was some sort of a fee split and it might have been semisecret. This was ghost surgery, the itinerant expert coming around to help the family surgeon. Now the term has an entirely different meaning, namely, that an experienced surgeon allegedly yields the scalpel, without approval, to a young learner. Participation is of the essence. If the older person does not participate in decisions and in assistance and supervision, then the single-standard system is not working as it should. Examples are to be found where the teacher has actually left the hospital during a complex operation, carried out by the learner. This is clearly an abuse of the sharing of responsibility intrinsic to the single-standard system of residency training and surgery. Many will state that the single-standard system is just an ideal, unattainable for most. I wish I could state that we have perfected it in every aspect at our own institution. We have not, although most patients are dealt with in an openly acknowledged, single-standard system. There are still aspects where perfection is needed. There are also hospitals in which a single-standard system is quite difficult. Large, municipal, tax-supported hospitals may have so few on the staff ready and willing to teach the younger generation that residents take care of hundreds or thousands of patients without adequate supervision. This is a problem to be discussed openly and confronted by those who are in charge of large, urban hospitals. I will close by saying, again, that I believe that the surgical problem is merely a model. It is a paradigm because the patient's welfare is so easily lost sight of in teaching operative surgery, and the public appreciates the nature of this problem. And yet, the ethical aspects of postgraduate teaching in surgery touch every aspect of medicine and every postgraduate program, no matter what its field. I am convinced that the open, singlestandard system in which all patients are cared for in partnership with an older generation and a younger generation represents the ideal solution where the two moral imperatives seem to conflict with teaching and responsible clinical care. Bull. N.Y. Acad. Med.
THE SURGICAL INTERNSHIP AND RESIDENCY* FRANCIS D. MOORE, M.D. Elliot Carr Cutler Professor of Surgery Harvard Medical School Boston, Massachussetts
T HE central ethical problem in the surgical internship and residency is this: Can a young person-a raw neophyte-learn to operate skillfully, mercifully, and wisely without jeopardizing the welfare of the patient? Clearly, two moral values conflict: the moral imperative to teach a young generation and the moral imperative that each patient have the most skillful person available to operate upon him. Several subsidiary matters have received a lot of recent publicity, such as what does one tell the patient when a learner is at the wheel or the knife? Can a learner be at the scalpel while the teacher is really at the controls? Is this some sort of ghost operation or ghastly proxy fraud? Who gets paid for what and for doing which to whom? But all those questions, despite television and the headlines, are merely footnotes to the central problem: protecting the welfare of the patient while the resident is being taught a highly skilled act. Although this central problem is a major one, it is neither numerically nor statistically so prominent as often supposed. There are about 2,000 residency programs in the 7,500 hospitals in this country. They include about 40% of the beds; it is estimated that about 20% of the major surgical operations performed in the United States involve teacher-learner encounters. The rest, for better or worse, represent a classical one-on-one, doctor-patient contact, sometimes less satisfactory or less expert than those in which learning occurs under the guidance of an expert. But this relation of teacher to learner and its relation to the unspoken patient contract is not unique to surgery. It exists in medicine, pediatrics, psychiatry, and in such diagnostic work as radiology. The need for respon*Presented in a panel, Ethical Concerns in Clinical Teaching, as a part of a Symposium on Ethical Concerns in Modern Medical Education held by the Committee on Medical Education of the New York Academy of Medicine October 13, 1977. Address for reprint requests: Department of Surgery, Harvard Medical School, 10 Shattuck Street, Boston, MA 02115.
Bull. N.Y. Acad. Med.
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sibility and candor in these nonsurgical fields is generally underestimated. It is my impression that responsibility on many teaching medical services is much more glibly passed down with much less serious supervision than is habitual and routine in surgery. But surgery is selected for this program, I am sure, because it has a high public profile. It is a prototype, a model, that throws the whole problem into high relief. Because surgery involves a special manual and learned skill, it must be learned by doing. One cannot learn to play the piano by going to concerts, even if they are given by Horowitz, Rachmaninoff, or Van Cliburn. One must practice, and one must perform alone. The major points I shall consider are, first, the various historic solutions for the teaching enigma in surgery. Second, the numbers game: credentials, the number of surgeons to be trained, and the entry of government through the Federal Trade Commission to harass ethical standard-setting in medicine. Third, the double-standard versus the single-standard system of conducting teaching hospitals. Finally, I shall propose what I think is the most acceptable solution. Historic solutions offered for this enigma offer much amusing and instructive medical history. The first and most ancient solution to the tranining enigma is what might be called the "little-to-big" system whereby the self-taught general practitioner progresses to become a general surgeon. This is on-the-job learning, and every patient is at hazard. We may laugh at this, but it is the ancient American tradition of the frontier. It is part of our open society. That the American Medical Association generally has taken a negative view of advanced residencies has its grassroots origin in this typically American concept, that anyone can do anything, and all one has to do is try. The British had a different viewpoint throughout their history. When King James IV gave that charter to the Royal College of Surgeons at Edinburgh, he said in effect: "You do it, you're the people to do it and to teach others." But he also said a very interesting thing in that first charter. He said, "No one else will be allowed to do it." The Royal Charter gave the surgeons the responsibility for both practicing and teaching and with it the monopoly. The British government favored monopoly while ours detests it and wishes to open surgical practice to all. Ethnic and national traditions sometimes are in striking contrast. The second historic method has been apprenticeship. It had certain virtues. The old Mayo Clinic fellowships in surgery were just that. Many Vol. 54, No. 7, July-August 1978
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do not realize that the Mayo Clinic training programs in surgery were not approved by the American Boards until very recently. The apprentice relation appeared to stifle individual learning performance, yet many eminent surgeons graduated from the Mayo Clinic system. Now the Mayo Clinic has replaced their old fellowship system by a standard surgical residency, involving graduated, personal responsibility and acceptance for training. Despite all this historical development, there is a general tendency to scorn an apprenticeship system, because it basically involves a single learner working with a single, older person over a prolonged time, with little opportunity for that learner to see other ways of doing things. Another historic method used on both sides of the Atlantic Ocean was the didactic, postgraduate course. This involved lots of lectures and didactic sessions, including illustrated lectures of surgical operations, and was followed by a lot of examinations, but the student had very little or no contact with patients. If he passed all this he was given a diploma. Reduced to absurdity, this was the British F.R.C.S. system in 1925. People arrived from the Empire, Africa, or India, studied for months or years in London, and finally took an examination. If they passed this examination, they became Fellows of the Royal College, and success was assured back home. But sometimes, even if they failed, they could claim some virtue for having been there and taken the examination several times. The American system, whatever its subsequent faults, was an immediate improvement on this sterile, didactic approach. From Halsted on, it emphasized contact with patients and individual responsibility. Thus we come to the Halstedian, two-standard system based on the ward patient, virtually always black, in the Baltimore of 1895. I was a little shocked to hear Dr. Stanley E. Bradley praise the ward patient as good teaching material because of lesser affluence and privilege. For all the virtues of the Halsted residency, we have come to view this type of segregation of a less privileged population, as elitist and essentially a thing of the past. While we accept a resident's service (under the professor), we have come to view the concentration of welfare cases, often of a special race or minority group, taken care of exclusively by residents and without guidance from the attending staff as very undesirable. That was the double-standard or two-standard system at its peak. Today we often deal with a modification of this that might be called the "limping or cover-up one-and-a-half standard" system. This governs much American graduate teaching today. The patient is not quite sure who Bull. N.Y. Acad. Med.
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is in charge or who is doing what. Neither, often, does the learner. Frequently the teacher has not really planned it out in much detail. The patient may be rich, poor, sophisticated, or not. This represents surgical training in transition. The system seems to work most of the time because of reasonable intelligence on the part of all, reasonable trust and good will on the part of the patient, and reasonable supervision by the teacher. And finally we come to the open, acknowledged, one-standard system of postgraduate education, not only in surgery but in medicine, pediatrics, radiology, pathology, psychiatry, radiotherapy, and all the rest. In the single-standard system, all patients who enter the door of the hospital, the emergency ward, or the outpatient department acknowledge that their care will be managed by a team that basically consists of two individuals, a teacher and a learner although, there may, of course, be others in both roles. The care and responsibility and the actual physical care are shared by both members of the team, always with adequate supervision. In the single-standard system the teacher-learner relation is assumed. Viewing any system of surgical training, we tend to concentrate on the ethical aspects of the operation itself. Perhaps we tend to overemphasize that one aspect. What is the patient's understanding of the nature of the contract regarding the rest of his care? Is the physician's responsibility limited just to the operation? Should we not raise the same questions about "ghost surgery" when we consider who gets up at night to examine the patient's acute abdomen, who writes the intravenous order, who talks to the troubled family over the telephone, who plans the roentgenograms, prescribes the antibiotics, the morphine, or the digitalis? Where did we get the idea that the surgical operation was the only place that involved an important ethical transaction as regards teacher and learner? In the single-standard system all these aspects are openly shared by both, with supervision by the teacher and participation by the learner. It is always a little shocking to visit a teaching hospital in which the older man, the teacher, does the operation from start to finish in an entirely nonsharing mode, only to leave the hospital and go somewhere else or home to bed for the night, leaving 100% responsibility for all other aspects of the patient's care to the learner. This is obviously an unhealthy principle and an unethical situation. In the single-standard system the teacher would have shared the operation with the learner and would have taken a greater part in the subsequent events. Another assumption to be examined is that the learner is always an Vol. 54, No. 7, July-August 1978
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individual with inferior ability. Age and education differ, and the older person should bring experience and possibly greater wisdom, but the younger may bring more vigor, new ideas from more recent exposure to basic sciences, more participation in the interdisciplinary atmosphere of medical school and the first hospital years. That younger person, whom we categorize as the learner, is frequently somewhat of a teacher himself with special skills. He brings far more to the encounter than blundering ignorance. In fact, the older individual will often work more efficiently and effectively in partnership with a younger person. The ideal interphysician contact of two people involved in patient care is an older person working with a younger person. The two generations work well together. The older-younger partnership has been a tradition in medicine since ancient times, and its open acknowledgement is one of the best features of the single-standard system. The word doctor means teacher and recognizes the intrinsic teaching function of any physician in contact with the younger generation. Turning to the "numbers game," consideration of the number of trainees relative to national needs enters our ethical discourse because overexpanded training programs leave physicians with an inadequate practicing base and inadequate experience as residents, while programs that are under-recruited and not large enough to meet national needs fail to meet the moral imperative to teach medicine at the postgraduate level. We will not review detailed numbers of the total number involved in surgical practice and residency training here, except to emphasize that the recently completed National Surgical Study (SOSSUS) demonstrated that the number of board-certified surgeons in this country was probably adequate to do the job and possibly a little more than adequate, that far too many physicians without any credentials for surgical training perform major operations, and, finally, that the residency pipeline of trainees in progress graduates too many people each year. A continued, rather alarming growth in the size of the surgical establishment is in store for the next few years. That study concluded that the one step needed at this time was to reduce the size of the residency-training force in surgery, to provide each learner with better experience in his hospital years, and to send somewhat fewer graduates into the practicing cohort. Such a restriction, whether voluntarily or through some sort of edict, would necessarily involve the assumption by hospital trustees and the public at large that only trained surgeons should carry out major surgery. It Bull. N.Y. Acad. Med.
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653
is historically interesting that now, in the latter portion of the 20th century, we appreciate the potentially monopolistic overtones of the credentialing system. It is quite wasteful and chaotic to mount an elaborate and carefully monitored training program in a field of medicine if, upon completion, there is no restriction of practice to those who have been through the training. Stated in simple terms, standards of excellence in achievement during the postgraduate years must be accompanied by suitable credentials and supervision at the hospital level to assure the patient that the individual performing the operation has actually completed training. While we are discussing this with relation to surgery, it is important to emphasize that precisely the same relation exists in radiotherapy, in certain aspects of cardiology and psychiatry, and in certain consultant areas of internal medicine. In all areas where the physician carries out acts of mercy that require skills and are hazardous if poorly performed, the public will require the protection of documented credentials of training and achievement. Should not a patient bothered by uterine bleeding somehow be assured of the skill of the person who does that simplest of all gynecological operations, dilatation and curettage? Should she not be assured that her surgeon knows the possible diagnostic components and is supported by a good pathologist and radiologist? This requirement of assurance for the public is not confined to surgery, but is an ethical aspect of postgraduate training handled by advanced licensure in many western European countries. We have no advanced licensure system in the United States. Instead, we have the American Board Examinations. Standards of educational achievement must be set, with documented proof of passage to protect the public. Thus, credentialing is an ethical problem intrinsic to the residency training, and yet, giving an examination and selecting those who pass is, in essence, a form of discrimination. This discriminatory aspect and the potential for monopoly have recently attracted the attention of the government through the Federal Trade Commission (FTC). We can express the hope as members of the public and as tax payers that the FTC will enter this arena with full appreciation that some degree of monopoly and discrimination is intrinsic to any set of standards established to protect the public. The sort of licensure that permits a pilot to fly the Atlantic, even the sort of licensure that lets a plumber or electrician repair one's home, is discriminatory and in a sense monopolistic but absolutely essential to protect the public. Vol. 54, No. 7, July-August 1978
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The question often arises, what is the evidence that the fully trained surgeon is any better, wiser, more honest, or more skillful than others? There is little evidence, and, in fact, it would be very difficult to collect such evidence in any westernized country today. In fact, it is a specious and misleading question. What is the evidence that a 747 pilot can fly the Atlantic Ocean in a large airplane better than one licensed only to fly a Piper cub? Do we have to run a double-blind trial to see how many crashes occur in both hands? Obviously not. The public will insist on an external measure of skill and achievement for those permitted to carry out hazardous acts of public service. The fallibility of examinations is acknowledged. The discriminant aspect of credentialing is evident: some will be more competent than others. Nonetheless, the public expects and deserves some arrangement to document the completion of adequate training. This may seem a long digression in a discussion possibly intended to bear on "ghost surgery." Yet the very existence of residency training and its current appreciation by the public is justified by a postgraduate curriculum, passing examinations, the presentation of credentials to the public, and limitation of that skilled work to those with the credentials. It seems to me that the most appropriate ethical climate for postgraduate residency training in the United States today is the single-standard system. I believe I have discussed it enough to make it clear how it works; it views all the patients within a hospital as cared for by a team in which the older generation (teachers) work in partnership with the younger generation (learners). It appreciates that the younger generation brings a great deal to the welfare of the patient, and that this doctor-student relation is a historic one in medicine, honored in the Hippocratic Oath. Obviously, a host of details cannot be discussed in this short period. The degree of participation of both, the manner in which the patient comes to understand this system, and the matter of discrimination and taste in selection of those components of the care process to be carried out solo by the learner- all these are important details of the single-standard system, and failure to discuss them elaborately today is a product of time constraints rather than failure to appreciate their importance. I should like to mention one aspect, bearing specifically on surgery: the selection of the individual who is actually to perform the act of operation-to wield the scalpel-according to the patient's disease rather than the patient's socioeconomic status or race. In the single-standard Bull. N.Y. Acad. Med.
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system, a patient with a very complicated pulmonary neoplasm, a difficult rectal tumor, an invasive kidney cancer, or a very complex aortoiliac vascular reconstruction is operated upon by the more experienced individual, whether that patient comes from the mansions along the Hudson River, or the lower East Side, whether the skin color be black, white, or yellow, whether the bank account runs into six figures or a deficit. By the same token, the patient with a perfectly straightforward appendicitis, cholelithiasis, thyroid nodule. or carcinoma of the colon is operated upon by the learner, always with the supervision and suitable participation of the teacher, and without reference to socioeconomic or racial factors. This allocation of the manual components of surgery according to the complexity of the patient's disease rather than his social status comes as somewhat of a shock to an older generation raised in the Halstedian system. It also comes as somewhat of a shock to the public. Many individuals with high incomes and elaborate social and educational backgrounds, assume that somehow they will never be touched by an intern, resident, or student. At the same time, many individuals of humble background approach the hospital with the almost certain knowledge that the boss will never come to see them. One of the most appealing aspects of the single-standard system of training is the obliteration of these ancient assumptions. They will not disappear rapidly, and it is going to take a lot of people preaching the message of the single-standard of residency training to bring it to pass. At the beginning of this talk I indicated that surgery is always selected for these discussions because it is such a spectacular example of individual responsibility at the operating table. Yet I cannot emphasize too strongly that the selection of the right dose of insulin or digitalis, the performance of the lumbar puncture in a patient with elevated cerebrospinal fluid pressure, the reading of the roentgenograms in a patient with a peculiar skeletal shadow, and the selection of the treatment port in a patient with a simple, small skin cancer make abundantly clear that ethical standards in postgraduate residency training are not in any sense confined to surgery. We may be up against a problem that forces us to find a way. But if we find that way then that is a way appropriate for other fields of medicine. The single-standard system has many other consequences. The younger and the older join in follow-up, in seeing patients together early and late, in preoperative, preadmission, or postoperative management. It may begin to look like an apprenticeship if the older person and the younger are Vol. 54, No. 7, July-August 1978
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always the same individuals. But as long as they change around, as they do in modem teaching hospitals, then we are dealing with an ethically acceptable and at the same time pedagogically sound residency program. What happens to ghost surgery in all this? In the old days, ghost surgery referred to an itinerant teacher, and now refers to the resident learner. Very few people are aware of this remarkable change in the meaning of the term. Around the turn of the century a general practitioner carrying out a difficult operation often called in a consultant from the big city who came and helped him through it, there was some sort of a fee split and it might have been semisecret. This was ghost surgery, the itinerant expert coming around to help the family surgeon. Now the term has an entirely different meaning, namely, that an experienced surgeon allegedly yields the scalpel, without approval, to a young learner. Participation is of the essence. If the older person does not participate in decisions and in assistance and supervision, then the single-standard system is not working as it should. Examples are to be found where the teacher has actually left the hospital during a complex operation, carried out by the learner. This is clearly an abuse of the sharing of responsibility intrinsic to the single-standard system of residency training and surgery. Many will state that the single-standard system is just an ideal, unattainable for most. I wish I could state that we have perfected it in every aspect at our own institution. We have not, although most patients are dealt with in an openly acknowledged, single-standard system. There are still aspects where perfection is needed. There are also hospitals in which a single-standard system is quite difficult. Large, municipal, tax-supported hospitals may have so few on the staff ready and willing to teach the younger generation that residents take care of hundreds or thousands of patients without adequate supervision. This is a problem to be discussed openly and confronted by those who are in charge of large, urban hospitals. I will close by saying, again, that I believe that the surgical problem is merely a model. It is a paradigm because the patient's welfare is so easily lost sight of in teaching operative surgery, and the public appreciates the nature of this problem. And yet, the ethical aspects of postgraduate teaching in surgery touch every aspect of medicine and every postgraduate program, no matter what its field. I am convinced that the open, singlestandard system in which all patients are cared for in partnership with an older generation and a younger generation represents the ideal solution where the two moral imperatives seem to conflict with teaching and responsible clinical care. Bull. N.Y. Acad. Med.
