2002 APDS SPRING MEETING: PART I

Presidential Address: ProgramDirector—What Kind of Job Is That?

Timothy Flynn, MD

Shands Health Care, Gainesville, Florida

Before I start, and it is traditional for talks of this nature, Iwould like to acknowledge a number of individuals who havebeen influential in my life as a surgeon. as you know, surgeonstend to be fairly hierarchical, and we are remiss if we do notacknowledge those who gave of themselves to train us. I suspectthis need to give back something to the profession is why manyof us do what we do.

Dr. Stanley Dudrick accepted me in his program at the Uni-versity of Texas at Houston as a PGY-2 after my tour in theNavy. Those of you over the age of 50 or so will remember thatit was common at that time for people to do an internship at oneplace and then have the opportunity to serve America for aperiod of time. I must say that this is a concept not withoutsome merit. Dr. Dudrick was kind enough to take me in, eventhough I had a long beard and long hair and had just spent ayear in Antarctica taking care of penguins. In reality, I havealways suspected he had a hole in the schedule and would havetaken anyone with a pulse. Be that as it may, he is an excellentteacher and he and his department imparted strong valuesabout the importance of total dedication to patient care, deci-sion making based on scientific principles, and the mind set thatsaw clinical problems as an opportunity to discover practicalsolutions. Dr. Dudrick also offered me my first academic job asa trauma/vascular surgeon when I finished the residency in1980. This was perfect as I was recently married and Marian,my wife, had just started her cardiology fellowship.

In 1983, I was making rounds and received a page from TedCopeland. Ted was on the faculty at the University of Texaswhile I was a resident and had become Chairman at the Uni-versity of Florida the previous year. My wife and I had agreedwhen we got married that we would never live in Florida, butsince it was Ted calling, we eagerly took the opportunity to lookat jobs at the University of Florida, and we have been there forthe past 18 years. Ted is a people person, and from him I havelearned quite a bit about how orgainzations work and about thelessons of leadership. His mentorship and support all these yearsis greatly appreciated.

I would also acknowledge J. Patrick O’Leary who first gave

me the opportunity to participate in this organization. I got toknow Pat on a boondoggle trip to China arranged by one ofPat’s old college pals. In reality it was my wife that was invited,but I was allowed to tag along. Much to the initial concern ofPat and his friend, we imposed our kids, then ages 7 and 9, onthem. Well, the kids were a hit, and Pat and I have remainedfriends since. From Pat, I take the example that everyday shouldbe fun and that while what we do is deadly serious, you can’ttake yourself too seriously in the process.

And also, of course, thanks to you, the members of theAPDS, who have afforded me the privilege of this presidency.

Having a blank page in front of you to talk about virtuallyCorrespondence: Inquiries to Timothy Flynn, MD, Shands Health Care, P.O. Box 100321,Gainesville, FL 32610; fax: (352) 265-8966; e-mail: flynn@mail.surgery.ufl.edu

Dr. Timothy Flynn

CURRENT SURGERY • © 2003 by the Association of Program Directors in Surgery 0149-7944/03/$30.00Published by Elsevier Science Inc. PII S0149-7944(02)00693-1

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anything you wanted to is somewhat intimidating. So I thoughtabout what I would do if I was writing a paper and went to thecomputer, called up Pubmed and typed in “presidential ad-dresses”. This returned 1776 citations. Knowing that I wouldnever read that many, I limited it to presidential addresses insurgery and found that there were still 330 citations. Thisproves, as my wife says, that there are way too many clubs insurgery. I limited the search to the last 10 years and found 82citations, including one entitled “Past Presidential Address”given by none other than our own J. Patrick O’Leary.

Thirty-five of the addresses spoke to the issue of education inone form or another. So, as nearly as I can tell, every 4 monthsor so, some surgeon feels it necessary to discuss surgical educa-tion in their presidential remarks. Mind you, these are only thetalks that were published and then picked up by the citationindex. However, I think it does make a statement about thesubject of surgical education and its importance and perhaps itsprecarious nature at this junction in history.

As I looked at some of these talks and reflected on priorpresidential addresses I had heard, I could group them intopatterns. Some of the talks were humorous; others could bedescribed as “woe is me” talks. These usually decried the unrea-sonableness of governmental policy or the loss of the time-honored values that are really what surgery is all about. Sometalks were very personal; others were scientific, and others werehistorical. However, the ones that were most often cited insubsequent articles were those that made some concrete propos-als for changes in the way things are done, and it is that sort oftalk that I propose to give to you today.

WHO ARE WE AS PROGRAM DIRECTORS?

This year’s match data listed 243 programs offering a total of1039 categorical PGY-1 positions and 205 programs offering980 preliminary positions. Interestingly, the ACGME/AMAdatabase lists 255 programs, and I have never been able to finda satisfactory explanation for this discrepancy. Nevertheless, thetotal number of programs seems relatively stable, at least overthe last several years, whichever data set you use. The ACGME/AMA database for 2000 also indicates that there are 7548 sur-gical residents or 7.8% of the total resident complement of96,806. A total of 22.6% of all surgical residents are female, and82.4% are graduates of United States medical schools. It isinteresting to note, in keeping with comments that have beenmade in this organization for the last 2 years, that there contin-ues to be a declining interest by U.S. seniors for surgical resi-dencies. This year only 75% of those that matched in the cate-gorical PGY-1 positions were U.S. graduates. We havediscussed the causes for this at great length, but at the very leastwe should take this opportunity to look at ourselves as much aswe look at the outside forces that affect us.

With regard to the 255 programs directors, I count only 12women. We are overwhelmingly a group of middle-aged whitemales. I challenge you to look around your medical school andsee whether this demographic reflects the students of today.

Most medical schools have a hall where they hang the picturesof the graduating class. I was in that hall in our school last weekand looked at the faces of the class of 1974, which would havebeen the year that I graduated from medical school, and then atthe faces and names of the class of 2001. I was struck by thedifferences. I will leave you to your own conclusions about whatthat observation may mean for you.

Almost 20% of us are new to the job this year, and theturnover in surgery program directors over the last several yearshas consistently been in the 20% range. Among all programdirectors this year, the turnover rate was roughly 14%. Whatdoes this say about the job of program director? What otherindustry would tolerate a 20% turnover every year in its keymanagement personnel?

Again, looking at the names of the program directors, I notethat in the 125 academic programs, few of those listed as pro-gram directors are chairs, and those listed as chair and programdirector frequently task another faculty member to do all thework. Since most of us are not academic chairs, it means that wefrequently do not sit at the focal point of power, i.e. the budget,which makes our jobs, in many instances, all the more difficult.This is not to argue that all program directors should be chairsas it is in some specialty program requirements, but there mustexist a strong relationship and an alignment of values betweenthe chair and program director. Realistically, this becomes in-creasingly problematic, as the job of program director becomesmore complicated and as the demands made by the externalenvironment on the program director and on the residents in-crease. Frequently these requirements and the expectationsmade by the institution on the chair are at odds. This conflict isexacerbated in situations where the chair is out of touch withsome of the new realities of residency training.

So, on the whole, we are relatively new to the job, we do notreflect the demographics of our residents or recruits, and we donot sit at the fulcrum of institutional change. We lead a work-force poorly versed in the requirements and may not have thetime or training to do anything about it.

So far, it sounds like a great job.

WHAT ARE OUR QUALIFICATIONS?

At the very least, we are all licensed in the states in which we live.We hold hospital privileges. We are all board certified in surgeryand presumably all recertified when the time comes. We allpossess the “requisite administrative abilities and experience,the dedication to surgical education and scholarship” that isrequired by the ACGME. Perhaps the most important thingthat we share is the requirement that we have all experienced asurgical residency—potentially a mixed blessing. Because, forbetter or for worse, our teaching style and our administrativestyle usually reflects how we were taught. Just as it is difficult toparent differently than the way we were parented—how manytimes have you heard your mother’s or your father’s wordsintentionally or unintentionally coming from your ownmouth—it is difficult to teach differently than we were taught.

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Unless we have made a considerable effort to learn new skillsand to have others critically evaluate our own teaching andmanagement efforts, we will find it difficult to embrace theinevitable changes we will encounter on our careers. Although itmay not apply to the individuals who consistently attend andparticipate in this organization, professional developmentamong the program directors in surgery is an issue that couldbear some attention. At best, most program directors were se-lected because they showed an interest and at least some apti-tude for the job. Few have been specifically trained to be respon-sible for a residency training program. At worst, individuals areappointed because no one else in the department wants the job.

As the Associate Dean for graduate medical education in myown institution, and speaking for that institution, I can say thelevel of experience and preparation for becoming a programdirector is highly variable, and I would assume that this is thesame at other institutions. As one of my new program directorstold me the other day in a masterful bit of understatement,“there really is a lot to this job.”

SO WHAT IS THE JOB OF THE PROGRAMDIRECTOR?

Like so many things, it depends on whom you ask. TheACGME and our own RRC have a long list of what it is weshould be doing. The program requirements for 2001 lists 97instances of the use of the word “must”, 23 instances of theword “should,” and 19 instances of the word “may.” This con-trasts to 1991 when “must” was used only 64 times and“should” 7 times. The current requirements reflect an increasein complexity, and the epitome of that, of course, is the issue ofthe competencies. Frankly, I think we teach all of the skillsdescribed on a daily basis and always have. Few would deny thatmastery of each of these attributes contributes to a successfullypracticing physician and the kind of individual we would like tohave in our hospitals and on our staffs. The complexity comes inidentifying tools to measure the acquisition of these skills inways that those outside the profession find acceptable. It seemsno longer acceptable to say that competency is like beauty—weknow it when we see it. At some level this is a reflection of theerosion of public trust in our profession that has occurred overthe last decade. We no longer have the professional autonomyto say that in our opinion an individual is competent withoutsome data to back that up. Further example of this concern forwhat is going on in our training programs by the public is theissue of work hours and its impact on patient safety. This hasand will result in much more prescriptive rules and oversight bythe ACGME. Regardless of the reasons for these new rules, thesense that there are too many unfunded mandates has created atension between the acreditating body and those acredited. In-creasingly, we have a hostile relationship between the ACGMEand the program directors. This is, in my mind, analogus to alabor–management dispute and is one that jepardizes theframework of the accreditation process. One of the greatestfears of the ACGME is that a framework of regulation, codified

in law by a governmental entity, will replace the system ofaccreditation by a non-governmental, professional organiza-tion. I leave it to your own imagination about how much fun itwould be to work in that environment.

Residents also have some ideas about what we should bedoing as program directors. They expect us to provide themwith the skills to make a living being a surgeon. They want tomaster cutting edge technology and to find their niche inwhichever practice environment they choose to enter. On thewhole, residents want to be taught, they want to feel part of theteam, and wish to be treated with respect. They frequently lookto us to help them deal with the stresses of learning the enor-mous responsibility inherent in our profession. Increasinglythey want to have a life of their own. Their expectations and lifeexperiences frequently differ from our own, and we must learnto deal with that reality. I remind you about the change in thecurrent medical school class compared to 20 or 30 years agowhen many of us were in school. How prepared are we tomanage this diverse group of trainees?

Over half of our graduates go on to obtain further trainingafter finishing our programs. Perhaps they are uncomfortablewith the breadth of the body of knowledge necessary to practicegeneral surgery and wish to find some small domain in which tobe an expert. Perhaps they feel they need a “gimmick” in orderto successfully compete in the market place, or perhaps theylack a residency role model of a practicing general surgeon whoenjoys his or her work and its diversity. Some seek furtherspecialization to find ways to control their lifestyle or for issuesof future earning potential. To what degree does our trainingscheme take this into account? Should it change to accommo-date this reality? This debate is reflected in several of the discus-sions we will be having at this meeting and is one that I think iswell worth having.

The organizations in which we work have put a number ofdemands on us. They wish to have the work covered, and in thepast, the residency programs have expanded to fill the workneeds of the academic health care centers. However, this iscoming to a grinding halt. My analogy is a balloon within aballoon. The small balloon is the volume of work needed totrain in the speciality and the amount of work that can safely betaken care of by the residents and faculty in the teaching hos-pital. This balloon can’t get any bigger and in fact is shrinking.The academic medical center, however, has increasingly grownto a size where patient care demands are well beyond the carecapacities of the residents and teaching staff. This is the largerballoon, and none of us have come to a good solution on how todeal with the work needs represented by the volume betweenthe small balloon and the large balloon. Academic medical cen-ters are described as one of the most complex organizationalstructures in our society, and changing the service/educationbalance of our training programs as the current reforms purportto do, and as right as that may be, will put no small amount ofstress on faculty and finances. Program directors must clearlyarticulate and defend the educational mission of the trainingprogram. We do this best by understanding the pressures faced

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by the leadership of the academic medical centers and partici-pating in a positive way to the solutions.

The public has voiced increasing concerns about what goeson in training programs. Lack of supervision and long workhours have been hot topics in the media. Dr. Wallach elo-quently described the journalistic field day that the papers inNew York have had over both of these topics. A series of articlesin the Cleveland Plain Dealer has prompted a GAO review ofsupervision in the VA. Just last week, The New York Times hadanother report on a patient who died after liver donation andsuggested that supervision of residents was an issue. JCAHOhas issued new rules about supervision. Combine this with theIOM report on patient safety, and I can see further restrictionson what residents can do. We all recognize the balance betweenpatient safety and training. Both missions have value; yet thereexists some tension between them. Managing that tension forthe maximal good is what we get paid for. We can only do thisif we have the public’s trust, a trust that we may be in danger oflosing.

The public and certain segments of the public are increas-ingly strident about the issue of work hours. The intuitive il-logic of working 100 hours a week is more than they can stand.After all, were any of us ever able to describe to our mothers howwe worked the hours that we did during our residency? Billsbefore Congress and in the various states may make this an issueof law, not of professional practice.

Safety, supervision, work hours, education—they are all re-lated. unless we get the balance right we are in danger of traininga generation of shift workers whose first independent decisionoccurs on the day after they leave our training program.

As to what program directors want, perhaps I should speakonly for myself, but I would like some of what all the otherswant. I would like the training program to be based on soundeducational principles. I want a residency workforce that feelsthat they can see their families while at the same time learningthe skills essential to take care of sick people. I want our orga-nization to be financially healthy so that it can continue tosupport some of the missions that are not traditionally line itemfunded in our society, such as education. I certainly want thepublic to feel that care in the institutions that I spent my lifeworking in is safe and effective.

But I am also concerned about the transmission of surgicalvalues and tradition. I have no small amount of ambivalenceabout how the forces circling in the outside world will impactthose core values of my professional life. My analogy is that allof us carry around a box of rocks that we greatly treasure. Somerocks represent those values absolutely key in defining who weare, and without those we wouldn’t be of the same personality.Some of them, however, are things we like to have but couldpotentially do without. Some of us in surgery have no interest ineven opening our box of rocks to discuss which rocks we coulddo without. Others, some perhaps more pragmatic, are taking alook at our box and thinking hard about which are the keeperrocks and which we could give up.

SO WHY BECOME A PROGRAMDIRECTOR?

Some see the position as a route to academic advancement andpromotion. Increasingly, educational research is being recog-nized as a valid area of inquiry, but this is by no means universal.I always worry when I see young new faculty, despite theirenthusiasm, talent, and willingness to tackle the job, put intoessentially administrative positions with the expectations thatthis job will possibly be considered by the Dean’s promotionand tenure committee. I have seen in my own institution indi-viduals who were excellent program directors, but not thoughtworthy of promotion. From an institutional prospective, pro-gram directors are a bit like goalies. It doesn’t matter how manycitations you prevent, it’s the ones that get through that theyhold against you, regardless of how well the rest of your team isplaying defense.

Despite all of the issues we face, in conversations with manyof you over the last several years, I find that most programdirectors consider the job as something of a vocation and have areal sense of mission about their job. We tend to believe thatdespite the difficulties inherent in the position, the rewards ofbeing part of an individual’s development from novice to expertare worth the effort. We realize that the program director maynever be at the center of power in most of our institutions, butbelieve the contribution to the next generation of surgeons hasworth that transends the care of an individual patient or someincremental discovery in the laboratory. Perhaps there is a bit ofsurgical immortality for each of us that occurs with each grad-uating class. I always find the thought that something I taught aresident may save some person I never met to be comforting.

Medical schools only do one thing that is unique—conferthe MD degree. Patient care and research can and are done inmany other types of institutions. Some would argue better doneat that. Residency programs similarily have only one uniquefunction and that is to attest to an individual’s readiness forindependent practice. We decide who will practice surgery inthis country in whom we accept into our programs, in the waywe lead, and in whom we let finish. So why do this job? Becausein ways subtle and not so subtle, in ways we recognize, and inactions that we may not even acknowledge, we shape the surgi-cal workforce of this nation. At the end of the day, it is about thetimeless values of giving back to the profession and to the soci-ety. And that is honorable and meaningful work.

Is the job impossible even if we think it is important? Arethere things that can be done to bring about the changes we allbelieve are needed?

I started by saying there were some concrete proposals that Iwould make today, and so here it goes.

First of all, I think that there should be a national surgicalcurriculum that begins on day one of internship and continuesthroughout the professional life of the surgeon. The topics aretoo complex to expect every program to have the resources to besuccessful. The variation in practice across the country is simplytoo great to ignore. No small part of this is the variation in

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training we have allowed to persist and in fact encouraged overthe years. Program directors, chairs, and faculty are over-whelmed by all that they are being asked to do. This effortwould build on the work published by this organization, but itwould be more than a list of topics. I would envision educa-tional content in the form of syllibi, lectures, video, web-basedmodules, and all other tools in the modern educational arme-mentarium. I think this organization, the ASE, the Board, theACGME, and the ACS should partner to begin to provideprogram directors with an educational portfolio that addressesnot only surgical knowledge, but also the other myriad of skillsand behaviors that surgeons are expected to exhibit. I believethat this should include periodic testing and that the look, feel,and content of this should continue throughout a surgeon’scareer. The competencies have not just been adopted by theACGME, but also by the American Board of Medical Special-ties. The Board has been tasked with not just giving a periodictest for recertification, but rather to establish ways to measureongoing competency. Just as we are struggling with this in ourresidency training programs, the boards are struggling as to howthis can be done with the practicing physicians. However, if webelieve that life-long learning is important, the organizationsthat represent surgeons in this country should begin to putsome real effort providing the education and ensuring the mas-tery of the important skills that the public expects us to dem-onstrate. I call for this organization to show its support and tolend the expertise of the program directors in developing thismodel.

Secondly, in keeping with the observation that there is reallya lot to being a program director, I propose that the ACGMErequire accreditation for all new program directors. This orga-nization has been an excellent source of training and profes-sional development for program directors. However, not allprogram directors participate, and we have never really definedthe knowledge and skill sets necessary to be an effective programdirector. I think that all programs directors, within 6 months ofassuming a position, should attend a course that covers theessentials of the ACGME requirement, but in addition, coversall the other of things that we are called upon to do on a dailybasis. Those include counseling, being an educational resource,dealing with legal issues, dealing with impairment, dealing withhuman resource problems, managing a budget, functioning in acomplex organization, and the list goes on and on. I think thisrequirement for education will contribute to the program di-rector’s job satisfaction and perhaps reduce the amount of pro-

gram director turnover in our training programs. In addition, itis my feeling that there should be required continued education,specifically in the area of surgical training, for program direc-tors, to ensure that the program director workforce maintainsits competency. In conjunction with this, the ACGME shouldhold institutions accountable to show support for program di-rectors. Other program requirements stipulate the percentageof time the director must spent involved in managing the train-ing program. Such explicit support should be part of our re-quirements.

Lastly, because of my increasingly uneasiness about the rela-tionship between the accrediting body and those it accreditsand the concern that I share with some of the leadership of theACGME that the whole accreditation model is being threat-ened, I think that there needs to be a summit meeting amongthe leadership of the ACGME, the RRC, the College, the pro-gram directors, and the board to discuss surgical training and tomake it clear what resources will be needed to accomplish theagreed upon goals. In my opinion, the accrediation processshould be continuous, transparent, and collaborative. Toomany of us feel besieged by rules we have trouble comprehend-ing, an inspection process that can seem arbitrary, and decisionsthat do not invlove those charged with implementation. A clearand open discussion leading to a mechanism for ongoing dia-logue is urgently needed.

I want to thank you for the enormous privilege of beingpresident and having the opportunity to represent you nation-ally. I am grateful for the friendships and time shared withindividuals who are devoted to educating the next generation.When I started to think about what I might say today, I was alittle overwhelmed by the task. I felt like I was back in highschool and having to give a talk for this award that I won—Catholic Youth of the Year 1966 for the State of Louisiana. Inthat talk, I told the audience not to worry about the future ofAmerica, because this huge cohort of idealistic, talented youngpeople were ready to take the leadership mantle from the gen-eration that won WW II. Well, here we sit, and in a few shortyears, it will be our time to turn over the reigns of power to thenext generation and to stand and be judged by our stewardshipof the institutions we lead. Time is short, and we have much todo. I am not so naive to believe that all will agree with what Ihave said today, but I do trust that we can have a fruitful dis-cussion of the issues.

Thank you for your attention!!

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