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Bulletin JUNE 2019 | VOLUME 104 NUMBER 6 | AMERIC AN COLLEGE OF SURGEONS New pathways for medical student education
AMERICAN COLLEGE OF SURGEONS
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Contents
FEATURES
COVER STORY: New pathways for medical student education
address concerns of both students and educators 10
Tony Peregrin
2018 ACS Governors Survey: Burnout—a growing challenge 19
David Welsh, MD, FACS; Hiba Abdel Aziz, MBBCh, FACS; Juan C. Paramo, MD, FACS;
Peter Andreone, MD, FACS; David W. Butsch, MD, FACS; and Julian Smith, MB, BS, FACS
Collected papers of the ACS Metabolic Surgery Symposium: Part VII 25
American College of Surgeons quality and safety programs
in metabolic surgery 26
David B. Hoyt, MD, FACS; Eric Joel DeMaria, MD, FACS; Raul Rosenthal, MD, FACS;
Bruce Schirmer, MD, FACS; and John M. Morton, MD, MPH, FACS
|1
The American College of Surgeons and accreditation of metabolic surgery 31
Ninh T. Nguyen, MD, FACS; Natan Zundel, MD, FACS; Bruce Schirmer, MD, FACS;
and Shanu Kothari, MD, FACS
JUN 2019 BULLETIN American College of Surgeons
Contents continued
COLUMNS A look at The Joint Commission: Coming next month in JACS
Joint Commission focuses on strategies and online now 51
Looking forward 8 to detect, prevent drug diversion 41 Chapter news 53
David B. Hoyt, MD, FACS Carlos A. Pellegrini, MD, FACS, Luke Moreau and Brian Frankel
From residency to retirement: FRCSI(Hon), FRCS(Hon), FRCSEd(Hon)
SSC Women’s Committee hosts
Chicago Committee on Trauma NTDB data points: Bullet to the third annual leadership event 57
responds to intimate partner bean: Renal gunshot wounds 43
shootings 36 Check your inbox twice a week for
Richard J. Fantus, MD, FACS, and My ACS NewsScope 58
Chicago Committee on Trauma Richard Jacob Fantus, MD
Executive Board
SCHOLARSHIPS
ACS Clinical Research Program: NEWS Health Policy Scholars for 2019
Opportunities at Clinical Congress
In memoriam: Dr. Pruitt announced 60
2019 to increase surgeon
remembered as a leader in burns,
participation in clinical research 39
trauma, critical care 45 MEETINGS CALENDAR
Amanda Francescatti, MS;
Ronald M. Stewart, MD, FACS, and Calendar of events 64
Kamal M.F. Itani, MD, FACS; and
Leopoldo C. Cancio, MD, FACS
Judy C. Boughey, MD, FACS
Your ACS benefits: Unlock savings
2|
on products and services through
the ACS 50
Bradley Elliott, CAE
V104 No 6 BULLETIN American College of Surgeons
The American College of Surgeons is dedicated CLINICAL
to improving the care of the surgical patient
and to safeguarding standards of care in an
CONGRESS 2019
The Best Surgical Education. All in One Place.
optimal and ethical practice environment.
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Officers and Staff of
the American College of Surgeons
Henri R. Ford, MD, FACS Patrick V. Bailey, MD, MLS,
Officers Miami, FL Advisory Council FACS
Medical Director, Advocacy
Ronald V. Maier, MD, FACS
James W. Gigantelli, MD, FACS
Omaha, NE to the Board Christian Shalgian
Seattle, WA
PRESIDENT B.J. Hancock, MD, FACS, FRCSC of Regents Director
Barbara L. Bass, MD, FACS Winnipeg, MB (Past-Presidents) AMERICAN COLLEGE OF
Enrique Hernandez, MD, FACS SURGEONS FOUNDATION
Houston, TX Kathryn D. Anderson, MD, FACS
IMMEDIATE PAST-PRESIDENT Philadelphia, PA Shane Hollett
Eastvale, CA Executive Director
Mark C. Weissler, MD, FACS Lenworth M. Jacobs, Jr., MD, FACS W. Gerald Austen, MD, FACS
Chapel Hill, NC Hartford, CT ALLIANCE/AMERICAN
Boston, MA COLLEGE OF SURGEONS
FIRST VICE-PRESIDENT
L. Scott Levin, MD, FACS L. D. Britt, MD, MPH, CLINICAL RESEARCH PROGRAM
Philip R. Caropreso, MD, FACS Philadelphia, PA FACS, FCCM Kelly K. Hunt, MD, FACS
Iowa City, IA Fabrizio Michelassi, MD, FACS Norfolk, VA Chair
SECOND VICE-PRESIDENT
New York, NY John L. Cameron, MD, FACS CONVENTION AND MEETINGS
Edward E. Cornwell III, Robert Hope
MD, FACS, FCCM Lena M. Napolitano, MD, FACS Baltimore, MD
Ann Arbor, MI Director
Washington, DC Edward M. Copeland III, MD, FACS
SECRETARY Linda G. Phillips, MD, FACS Gainesville, FL DIVISION OF EDUCATION
William G. Cioffi, Jr., MD, FACS Galveston, TX A. Brent Eastman, MD, FACS Ajit K. Sachdeva, MD,
Providence, RI Rancho Santa Fe, CA FACS, FRCSC
Kenneth W. Sharp, MD, FACS Director
TREASURER Nashville, TN Gerald B. Healy, MD, FACS
David B. Hoyt, MD, FACS Anton N. Sidawy, MD, FACS Wellesley, MA EXECUTIVE SERVICES
Chicago, IL Washington, DC Lynese Kelley
EXECUTIVE DIRECTOR R. Scott Jones, MD, FACS Director, Leadership Operations
Beth H. Sutton, MD, FACS Charlottesville, VA
Gay L. Vincent, CPA Wichita Falls, TX FINANCE AND FACILITIES
4| Chicago, IL Edward R. Laws, MD, FACS Gay L. Vincent, CPA
CHIEF FINANCIAL OFFICER Gary L. Timmerman, MD, FACS Boston, MA Director
Sioux Falls, SD LaSalle D. Leffall, Jr., MD, FACS HUMAN RESOURCES
Steven D. Wexner, MD, FACS Washington, DC AND OPERATIONS
Officers-Elect Weston, FL LaMar S. McGinnis, Jr., MD, FACS Michelle McGovern
Douglas E. Wood, MD, FACS Atlanta, GA Director
(take office October 2019) Seattle, WA David G. Murray, MD, FACS INFORMATION TECHNOLOGY
Valerie W. Rusch, MD, FACS Michael J. Zinner, MD, FACS Syracuse, NY Brian Harper
New York, NY Miami, FL Director
PRESIDENT-ELECT Patricia J. Numann, MD, FACS
Syracuse, NY DIVISION OF INTEGRATED
John A. Weigelt, MD, FACS COMMUNICATIONS
Sioux Falls, SD Carlos A. Pellegrini, MD, FACS
FIRST VICE-PRESIDENT-ELECT Board of Seattle, WA Interim Director
F. Dean Griffen, MD, FACS Governors/ J. David Richardson, MD, FACS JOURNAL OF THE AMERICAN
COLLEGE OF SURGEONS
Shreveport, LA
SECOND VICE-PRESIDENT-ELECT Executive Louisville, KY
Timothy J. Eberlein, MD, FACS
Richard R. Sabo, MD, FACS
Committee Bozeman, MT
Editor-in-Chief
DIVISION OF MEMBER SERVICES
Steven C. Stain, MD, FACS Seymour I. Schwartz, MD, FACS
Board of Regents Albany, NY Rochester, NY
Patricia L. Turner, MD, FACS
Director
CHAIR
Gerald M. Fried, MD, FACS, FRCSC Courtney M. Townsend, Jr., M. Margaret Knudson, MD, FACS
Montreal, QC Daniel L. Dent, MD, FACS MD, FACS Medical Director, Military Health
CHAIR San Antonio, TX Galveston, TX Systems Strategic Partnership
VICE-CHAIR
James K. Elsey, MD, FACS Andrew L. Warshaw, MD, FACS Girma Tefera, MD, FACS
Atlanta, GA Ronald J. Weigel, MD, PhD, FACS Boston, MA
Iowa City, IA Director, Operation Giving Back
VICE-CHAIR
SECRETARY PERFORMANCE IMPROVEMENT
Anthony Atala, MD, FACS
Winston-Salem, NC Terry L. Buchmiller, MD, FACS
Boston, MA
Executive Staff Will Chapleau, RN, EMT-P
Director
John L. D. Atkinson, MD, FACS EXECUTIVE DIRECTOR
Rochester, MN Andre R. Campbell, MD, FACS DIVISION OF RESEARCH AND
San Francisco, CA David B. Hoyt, MD, FACS OPTIMAL PATIENT CARE
James C. Denneny III, MD, FACS DIVISION OF ADVOCACY Clifford Y. Ko, MD,
Alexandria, VA Taylor Sohn Riall, MD, PhD, FACS MS, MSHS, FACS
AND HEALTH POLICY
Tucson, AZ
Margaret M. Dunn, MD, FACS Frank G. Opelka, MD, FACS Director
Fairborn, OH Mika N. Sinanan, MD, PhD, FACS Medical Director, Quality Heidi Nelson, MD, FACS
Seattle, WA and Health Policy
Timothy J. Eberlein, MD, FACS Medical Director, Cancer
Saint Louis, MO David J. Welsh, MD, FACS
Batesville, IN Ronald M. Stewart, MD, FACS
Medical Director, Trauma
V104 No 6 BULLETIN American College of Surgeons
Author bios*
*Titles and locations current at the time articles were submitted for publication.
a b c
d e f
|5
g h i
DR. ABDEL AZIZ (a) is an acute care DR. BUTSCH (d) is clinical associate MR. ELLIOTT (g) is Associate Director, ACS
surgeon, Hamad General Hospital, Doha, professor, Larner College of Medicine, The Division of Member Services, Chicago, IL.
Qatar, and member, American College of University of Vermont, Burlington. He is a
DR. RICHARD J. FANTUS (h) is interim
Surgeons (ACS) Board of Governors (B/G) member, ACS B/G Survey Workgroup, and
chairman, department of surgery; medical
Survey Workgroup. She is the founding Past-President, ACS Vermont Chapter.
director, trauma services; and chief, section
Governor of Qatar Chapter of the ACS.
DR. CANCIO (e) is Director, U.S. of surgical critical care, Advocate Illinois
DR. ANDREONE (b) is a cardiac and Army Burn Center, U.S. Army Institute Masonic Medical Center, Chicago. He is
thoracic surgeon, Sioux Falls, SD, and of Surgical Research, Joint Base San clinical professor of surgery, University of
Chair, ACS B/G Survey Workgroup. Antonio-Fort Sam Houston, TX. Illinois College of Medicine, Chicago, and
Past-Chair, ad hoc Trauma Registry Advisory
DR. BOUGHEY (c) is the W.H. Odell DR. DeMARIA (f) is president, American Committee, Committee on Trauma (COT).
Professor in Individualized Medicine, Society for Metabolic and Bariatric
professor of surgery, and vice-chair, Surgery; and professor and chief, general DR. RICHARD JACOB FANTUS (i) is a
research, department of surgery, and bariatric surgery division, East fifth-year urology resident, University of
Mayo Clinic, Rochester, MN. She is Carolina University, Greenville, NC. Chicago, and a Resident Member of the ACS.
Chair, ACS Clinical Research Program
(CRP) Education Committee. continued on next page
JUN 2019 BULLETIN American College of Surgeons
Author bios continued
j k l
m n o
6|
p q r
MS. FRANCESCATTI (j) is Senior DR. KOTHARI (n) is director, department DR. NGUYEN (q) is the John E. Connolly
Manager, ACS CRP, Cancer Programs, of bariatric and minimally invasive surgery, Professor and chair, department of
Division of Research and Optimal Gundersen Health System, La Crosse, WI. surgery, University of California
Patient Care (DROPC), Chicago, IL. Irvine Medical Center, Orange.
MR. MOREAU (o) is Manager,
MR. FRANKEL (k) is Manager, International Domestic Chapter Services, ACS DR. PARAMO (r) is a surgical oncologist,
Chapter Services and Special Initiatives, Division of Member Services. Mount Sinai Medical Center Comprehensive
ACS Division of Member Services. Cancer Center, Miami Beach; associate
DR. MORTON (p) is vice-chair, professor of surgery, Florida International
DR. HOYT is (l) Executive quality; division chief, bariatric and
University Herbert Wertheim College of
Director, ACS, Chicago. minimally invasive surgery, Yale School
Medicine, Miami; and clinical professor
of Medicine, New Haven, CT.
DR. ITANI (m) is chief of surgery, Veterans of surgery, Nova Southeastern University
Affairs Boston Health Care System; professor Dr. Kiran C. Patel College of Osteopathic
of surgery, Boston University, MA; and Past- Medicine, Ft. Lauderdale. He is a
Chair, ACS Surgical Research Committee. member, ACS B/G Survey Workgroup.
continued on next page
V104 No 6 BULLETIN American College of Surgeons
Author bios continued
s t u
v w
|7
x y z
DR. PELLEGRINI (s) is professor and DR. SCHIRMER (v) is the Stephen H. DR. STEWART (x) is the Dr. Witten B.
chair emeritus, department of surgery, Watts Professor of Surgery and vice-chair, Russ Chair in Surgery, professor of surgery
University of Washington, Seattle. He is a department of surgery; division chief, and anesthesia, and chair, department
Past-President of the ACS and a member general surgery; and director, surgery of surgery, University of Texas Health
of the Board of The Joint Commission. nutrition support service, University of Science Center, San Antonio. He is Medical
Virginia Health System, Charlottesville. Director, Trauma, ACS DROPC.
MR. PEREGRIN (t) is Senior Editor, Bulletin
of the American College of Surgeons, Division DR. SMITH (w) is head, department of DR. WELSH (y) is a general surgeon
of Integrated Communications, Chicago. surgery, School of Clinical Sciences, Monash in Batesville, IN, and a member,
Health, Monash University, Clayton, ACS B/G Survey Workgroup.
DR. ROSENTHAL (u) is professor of Victoria, Australia, and head, department
surgery and chairman, department of DR. ZUNDEL (z) is professor of surgery
of cardiothoracic surgery, Monash Health.
general surgery; director, general surgery and vice-chairman, department of surgery,
He is President and Governor, Australia
residency program; director, bariatric Florida International University, Herbert
and New Zealand Chapter of the ACS.
and metabolic institute, Cleveland Clinic Wertheim College of Medicine, Miami.
Weston, FL; and co-editor-in-chief,
Surgery for Obesity and Related Diseases.
JUN 2019 BULLETIN American College of Surgeons
EXECUTIVE DIRECTOR’S REPORT
Looking forward
by David B. Hoyt, MD, FACS
S
ome members of the American College of Sur- lion affordable housing bond. She has added mental
geons (ACS) have indicated that they plan to health stabilization beds and authored conservator-
skip Clinical Congress 2019 because San Fran- ship legislation to help people who are suffering from
cisco, CA, is the host city. These surgeons point to mental health and substance use disorders.2
media reports and personal experiences with regard In fact, the city is investing $60 million in tempo-
to aggressive panhandling, dirty needles on the rary and permanent housing; $27 million in state fund-
street, and public defecation and urination, particu- ing for homeless programs; $6 million in developing a
larly in Union Square, which is near the headquar- drug addiction street team; $16 million in street clean-
ters hotel and the Moscone Center. They note that a ing services and equipment; $44 million in emergency
few other organizations have pulled San Francisco response services; and $300 million in long-term im-
from their roster of convention host cities and be- provement projects, such as street resurfacing, side-
lieve the College should follow suit. walk repair, and park improvements (personal commu-
I would urge people to reconsider attending Clini- nication with Rick Hud, senior manager, convention
cal Congress in San Francisco and to focus less on sales, San Francisco Travel Association, April 19, 2019).
the negative and more on the positive aspects of the To those individuals who say that crime is rampant
meeting and its host city. I also would encourage in San Francisco, the Major Cities Chiefs Associa-
them to consider the facts about public safety and tion reports that the city’s overall and violent crime
8| the many advantages of attending Clinical Congress rates are lower than that of New York; Los Angeles;
in this world-class city. Chicago, IL; and Denver, CO.3 In fact, according to
The Economist Intelligence Unit’s Safe City Index, San
Francisco is the safest city in the U.S. and 15th in the
Steps that San Francisco is taking world.4 The city’s homicide rate is at its lowest point
Like many big cities across the nation, San Francisco in 50 years.
does have a large number of homeless people, but it The city also has added 250 new police officers,
might interest you to know that its homeless popula- many of whom have been specifically assigned to po-
tion is smaller than that of several other metropolises. licing in and around the Moscone Center. The police
San Francisco has 6,857 homeless people. Compara- department has created a crime unit to deal directly
tively, San Diego, CA, has an estimated 8,576 home- with smash-and-grab crimes and has added more foot
less people; Seattle, WA, has 12,112; Los Angeles, CA, patrols. In addition, San Francisco Travel, the city’s
49,955; and New York, NY, 78,676.1 tourism bureau, has hired a retired San Francisco Po-
The reality is that many homeless people have lice Lieutenant to serve as a safety consultant.
mental illnesses and substance abuse disorders that Union Square now has Business Improvement De-
can lead to erratic behavior. San Francisco is tak- partment red-jacketed ambassadors to assist visitors
ing proactive steps to address these issues firmly but who are looking for directions to points of interest.
compassionately under the leadership of Mayor Lon- These individuals serve as additional “eyes and ears”
don Breed. A native San Franciscan, Mayor Breed has on the street and provide such services as sidewalk
made a significant investment in helping the city’s and gutter sweeping, graffiti removal, and sidewalk
homeless population gain access to health care and power washing. The city has installed 3,000 garbage
shelter, including opening more than 330 new shelter cans citywide, increased cleaning services, established
beds and getting nearly 1,000 people off the streets safe injection sites, and expanded the number of rest
and into affordable housing. She is focused on add- areas equipped with public toilets.
ing more housing for residents of all income levels by Hence, it seems reasonable to say that San Francisco
streamlining bureaucracy and cutting permit times is making a good faith effort to be a safe, clean, and
and intends to move forward plans for a $300 mil- enjoyable place to visit.
V104 No 6 BULLETIN American College of SurgeonsEXECUTIVE DIRECTOR’S REPORT
REFERENCES
Take in the culture and scenery 1. McCarthy N. The U.S. cities
And, of course, the city and its surrounding areas always have been with the most homeless people
home to many wonderful attractions that are fun and educational for in 2018. Forbes. Available
the whole family. If historic sites and museums appeal to you and your at: www.forbes.com/sites/
traveling companions, visit Alcatraz, the California Academy of Sci- niallmccarthy/2018/12/20/
the-u-s-cities-with-the-most-
ences, the Walt Disney Family Museum, the Cable Car Museum, the homeless-people-in-2018-
San Francisco Museum of Modern Art, and the Palace of Fine Arts. infographic/#4be77f411780.
If you prefer outdoor activities, you can bike across the Golden Gate Accessed April 30, 2019.
Bridge, take a San Francisco Bay Twilight and Sunset Cruise, visit 2. Office of the Mayor. About Mayor
Fisherman’s Wharf, go golfing, visit the sea lions at Pier 39, drive or London Breed. Available at: https://
sfmayor.org/about-mayor. Accessed
walk down Lombard Street, see the Victorian houses known as the April 30, 2019.
Painted Ladies, stroll around Chinatown, or hop the ferry to Sausalito. 3. Major Cities Chiefs Association.
And of course, for the gourmands, San Francisco has more Michelin Violent Crime Survey, January 1 to
star restaurants than any U.S. city. March 31, 2018 and 2017. Available
If you decide to add a couple of days to your trip, you can tour Yo- at: https://majorcitieschiefs.com/
pdf/news/mcca_violent_crime_
semite, check out the wineries of Napa Valley and Sonoma County, report_2018_and_2017_first_
wend your way through Muir Woods and see the giant redwoods, |9
quarter_update.pdf. Accessed April
visit the state capitol in Sacramento, and breathe in the fresh air of the 30, 2019.
Sierra Nevada range. Or cruise south down Highway 1 to Monterey or 4. The Economist Intelligence Unit. Safe
Carmel, stopping to explore the string of beach towns along the way. Cities Index: Security in a rapidly
urbanising world. Available at:
Many of these locations will be on the list of Guest Programs of- http://safecities.economist.com/
fered through the ACS during the Clinical Congress. Participation safe-cities-index-2017. Accessed April
in these tours ensures that your spouse, children, and other guests 30, 2019.
are visiting these attractions in a safe environment while you are
busy attending Panel Sessions and Skills and Didactic Postgraduate
Courses at the Moscone Center. For the youngest members of your
family, ACCENT on Children’s Arrangements, Inc., partners with
the College to provide an on-site Camp ACS for children ages six
months to 17 years old.
San Francisco has been a host city for the Clinical Congress for
decades and typically has drawn some of our highest attendance num-
bers, which should come as no surprise given all that the city and the
conference have to offer. I look forward to seeing you in October. ♦
If you have comments or suggestions about this or other issues, please send them to
Dr. Hoyt at lookingforward@facs.org.
JUN 2019 BULLETIN American College of SurgeonsMEDICAL STUDENT EDUCATION
10 |
New pathways for medical student education
address concerns of both students and educators
by Tony Peregrin
New pathways for medical student education
V104 No 6 BULLETIN American College of SurgeonsMEDICAL STUDENT EDUCATION
I
nnovative approaches to medical student education are largely
HIGHLIGHTS driven by two key factors: a projected shortfall of up to 120,000
• Describes creative approaches physicians by 2030 and escalating medical student debt, which can
to medical school education, average $150,000–$210,000 per graduate.1,2 Revisiting the traditional
including the three-year medical education model—two years of preclinical, classroom-based
model and the integrated learning followed by two years of rotations in a clinical setting—
curriculum with early clinical could reduce student debt and expedite graduation for a select group
exposure approach of students who would like to enter the workforce sooner.
• Identifies the College’s With minimal deviation, U.S. physicians have been trained in the
role in medical student same four-year format for more than 100 years, a structure that evolved
education and training based on the medical education reforms recommended by the Flexner
Report published in 1910.3,4 U.S. physicians average 14 years of higher | 11
• Outlines the challenges
education—four years of college, four years of medical school, and
of curriculum reform,
three to eight years of postgraduate training.5 This training period
including burnout and
achieving faculty buy-in
is much longer than in other developed countries, where students
typically study for 10 years.5 Could alternative approaches to medi-
cal student education in the U.S. not only save time and money, but
ultimately result in enhanced patient care provided by physicians who
learned in a blended clinical and classroom environment?
This article describes novel and emerging approaches to medical
student education, describes the challenges associated with major
curriculum reforms, and outlines the College’s role in advancing the
medical student training experience.
The three-year model
One innovation that has been introduced at eight U.S. institutions and
one Canadian university allows medical students to graduate in three
rather than four years (see sidebar, page 12). According to Travis P.
Webb, MD, MHPE, FACS, professor of surgery and associate dean of
curriculum, Medical College of Wisconsin, Milwaukee, his institution
offers two tracks: a traditional four-year track that trains approxi-
mately 205 medical students annually and an accelerated three-year
track that trains 20–25 students per year at two regional campuses.
“It took a couple of years of planning to determine the logistics
of how we would provide the same curriculum, in other words,
the same objectives and the same assessment models, for all of our
students—whether they’re on the Milwaukee campus or on the
JUN 2019 BULLETIN American College of SurgeonsMEDICAL STUDENT EDUCATION
“The ability to look up something quickly has
not yet altered the foundation of what we are
teaching, but certainly it’s going to alter it in the
future.... We need to react to that and to ensure
that our students are prepared to enter the
workforce and be competent for years to come.”
—Dr. Webb
Dr. Webb
regional campuses in Green Bay and Wausau—and to figure out
how we could compress the time such that students would get
THREE-YEAR MD PROGRAMS the same breadth of training and knowledge in a shorter amount
• McMaster University Michael G. DeGroote of time,” Dr. Webb said. “The way we ultimately decided to do
School of Medicine, Hamilton, ON this was to be very time intensive and to start the students in
clinical exposure and clinical training much earlier and to do
• Medical College of Wisconsin (Green away with many of the breaks [vacation time] that our students
Bay and Central Campuses) in Milwaukee have.”
• Mercer University School of According to Dr. Webb, the students in the accelerated track
Medicine, Macon, GA begin their first year in July instead of August. During this year,
• New York University School they begin to learn basic clinical skills, such as performing the
12 | physical exam and communication and professionalism com-
of Medicine, NY
petencies before moving into the more basic science portion of
• Penn State College of
the curriculum. In between the first and second year, students
Medicine, Hershey, PA
begin clinical rotations.
• Texas Tech University Health Sciences “At the Green Bay campus, students participate in a more
Center School of Medicine, Lubbock traditional clerkship model, where they do clerkships in family
• University of California, Davis medicine, psychiatry, and surgery, all in between that first
School of Medicine and second year. At the Central Wisconsin campus, however,
• University of Louisville
the program implemented a longitudinal integrated clerkship
School of Medicine, KY model, which allows students to experience the full breadth
of clinical specialties. They begin that in June after the first
year, and then they continue that training on both campuses in
Source: Cangiarella J, Fancher T, Jones B, et al. June of the second year. This model allows them to complete
Three-year MD programs: Perspectives from all of the required clerkship topics and diseases, exposures, and
the Consortium of Accelerated Medical Pathway
Programs (CAMPP). Acad Med. 2017;92(4):483-490. such during the third year,” Dr. Webb said. The program at the
Wausau campus is now in its third year, and the program at
Green Bay is entering its fourth year.
Some medical educators have expressed concerns about three-
year curricula, including the possibility of higher burnout rates
among students. Dr. Webb said it is important to recruit appro-
priate students for three-year programs. “You want to get the
right students, the right fit, for the institution and for the train-
ing model. It certainly helps to have mature students who have
a good idea of what they want to do with their life. I think many
of the students who do well in accelerated programs have had
a previous career, if you will, in nursing or some other type
of health care field and already have an idea of what it means
V104 No 6 BULLETIN American College of SurgeonsMEDICAL STUDENT EDUCATION
“I think it can be difficult for faculty to learn
new teaching styles.... This [new faculty
development] approach makes your faculty feel
more supported when they’re going through a
difficult time, and it improves the end product.”
—Dr. Fitzgibbons
Dr. Fitzgibbons
to be a health care provider. They have figured out of new teaching technologies that make this model
the drivers that allow them to persevere through the more viable than in the past.
challenges of rigorous medical school training,” he “We have been able to replace some traditional lec-
said. tures with podcasts, videos, and webcasts that allow
Another factor that may curb potential burnout at students to digest them, quite frequently, at an acceler-
the Medical College of Wisconsin is the small cohort ated speed, or they can slow it down or go back to areas
of students who are in the accelerated track. With that they need to review for clarity,” Dr. Webb said.
20–25 students per class, the faculty and dean are “The reliance on just book knowledge has decreased
able to develop a closer relationship with each student at point of care because you have access to information
and are able to recognize and ideally mitigate any via your mobile phone,” he added. “The ability to look
fatigue-related issues that arise. Students who seem up something quickly has not yet altered the founda-
to be struggling also have the option to decelerate tion of what we are teaching, but certainly it’s going | 13
into a standard four-year training model. to alter it in the future as we start dealing with more
Another common concern regarding an accel- potential for artificial intelligence in medicine. We
erated medical school program is the potential for need to react to that and to ensure that our students
reduced physician competency. Notably, a study of the are prepared to enter the workforce and be competent
Michael G. DeGroote School of Medicine at McMas- for years to come.”
ter University, Hamilton, ON—which has provided Dr. Webb also noted that simulation is making
three-year curricula for more than four decades— accelerated learning more possible. “The use of
found that “McMaster graduates were comparable simulation, whether it’s with live patients or using
to four-year graduates of U.S. and Canadian medi- high-fidelity simulators, has enhanced our ability to
cal schools in terms of performance on standardized prepare students for actual clinical encounters with
national examinations, preparation for and perfor- real patients. We have been able to use those types
mance during residency, ability to obtain preferred of situations earlier on, when it’s much lower stakes,
first-year residencies, and percentage pursuing pri- to allow students to have these encounters, provide
mary care.”4 them with feedback, and then allow them to take that
Similarly, Dr. Webb said three-year program knowledge and those skills directly to the clinic, where
medical school graduates score as well as four-year we have seen that they have a higher level of clinical
students on the U.S. Medical Licensing Examina- ability than [students in] the traditional curricula.”
tion, and their performance during residency is just A 2016 survey of approximately 280 medical school
as good as or better than four-year students. deans showed that 38 percent of the educators were
Three-year medical school programs are not a interested in an accelerated curriculum.7 “This is
novel concept and, in fact, were determined to be not a small number of education leaders who have a
suitable alternative education models during World strong interest in this pathway for multiple reasons,”
War II and in the 1970s, driven by physician work- Dr. Webb said. “I am hopeful and I am confident that
force shortages and a surge in the cost of medical many institutions are considering this, and I think we
education, much as the case is today.6 Furthermore, will continue to see an evolution of what the fourth
today’s medical students have the added advantage year of medical school looks like.”
JUN 2019 BULLETIN American College of SurgeonsMEDICAL STUDENT EDUCATION
“What we’ve seen [in the OSUMC Lead,
Serve, Inspire curriculum] is a progression
of our students to very few preliminary
and many more categorical positions.”
—Dr. Lindsey
Dr. Lindsey
Integrated curriculum with particularly difficult for us, is the segregation between
early clinical experience the faculty who teach the preclinical years and the
Educators at Georgetown University School of Medi- faculty who teach the clinical clerkships in the hospi-
cine, Washington, DC, have designed a new educational tal,” Dr. Fitzgibbons said. “And that is likely similar
pathway for medical students, which is tethered to a to a lot of other medical schools—this lack of integra-
curriculum that blends clinical experience with basic tion between those two faculty groups. Even though
science over four years.8 they are attending meetings together and designing
According to Shimae C. Fitzgibbons, MD, MEd, a curriculum together, at the end of the day, the pre-
FACS, MedStar Georgetown University Hospital, the clinical faculty go back to their offices and teach their
Georgetown model provides more student-driven courses, and the clinical faculty go back to the hospital
choices; that is, it is less prescriptive than a traditional and teach their courses.” Dr. Fitzgibbons noted that
14 | curriculum and gives students the opportunity to the courses that were easiest to update and modify for
figure out how to best use their time, with much more the new curriculum were the ones where course direc-
flexibility in when they take time off for interviews or tors were paired with one academic and one clinically
for research. active physician.
Georgetown also offers students interesting elec- The revised curriculum at Georgetown, which
tives or opportunities to engage in selective clinical rolled out in 2017, also is supported by new education-
rotations that they might not have been exposed to in based technology.8,9 At Georgetown and many other
the third year. “The traditional fourth year at George- institutions of higher learning, printed handouts have
town has shifted to starting even earlier. It is akin to largely been replaced by digital formats, including
making the fourth year even longer, which is in direct lecture-capture tools that allow instructors to record
opposition to how some other medical schools have what happens in their classroom for students to access
dealt with the issue, namely to truncate the medical later, as well as tools to convert PowerPoint slides and
school curriculum and make it more or less a three- other instructional aids into digital formats that are
year experience,” Dr. Fitzgibbons said. time-saving and adaptable to the student’s individual
Georgetown’s new curriculum includes approxi- learning style. These new technologies sometimes
mately 18 months of foundational science, then early allow students to watch a lecture before the class
entry into clinical rotations, followed by more intense meets, fostering more interaction between the students
study of basic science, but with students selecting areas and instructor, while the use of laptops and smart-
of basic science that complement their specialty inter- phones allows students to connect with in-classroom
ests.9 “This shift moves everything up and allows for a screens in real time to ask questions and engage with
longer tail at the end. They spend the fourth year doing peers and the professor.8
what they have selected to do rather than meeting core “I think it can be difficult for faculty to learn new
requirements,” Dr. Fitzgibbons said. teaching styles,” added Dr. Fitzgibbons. “We have a
A notable challenge of implementing this student- fantastic dean of assessment who’s really tried to push
centered, interactive-learning model was achieving faculty development around very specific best prac-
faculty buy-in. “I think one thing that has existed at tices on how to get students more engaged, how to
Georgetown, which might have made the challenge get them to do independent learning that’s actually
V104 No 6 BULLETIN American College of SurgeonsMEDICAL STUDENT EDUCATION
“This [joint ACS/ASE] curriculum provides the
students with the opportunity to learn these skills
earlier in their medical career and be assessed for
competency earlier, so that by...their fourth year,
they’re actually vetted and able to perform many of
the skills required for a physician of any specialty.”
—Dr. Steinemann
Dr. Steinemann
effective, how to keep checking back in to get more has been involved in the curriculum rewrite since the
informative feedback—even in the preclinical course beginning. “The interest level of the students also
work. This approach makes your faculty feel more is much higher. It’s much better if you’ve chosen to
supported when they’re going through a difficult time, take something rather than if you are compelled to
and it improves the end product.” take it to complete your program.”
In February 2018, the OSUMC’s executive curricu-
lum committee adopted the Association of American
Early clinical exposure Medical Colleges (AAMC)-endorsed Physician Com-
A three-part, four-year program at The Ohio State petency Reference Set (PCRS) as the core outcomes
University Medical Center (OSUMC), Columbus, of the LSI curriculum.12 Although these competencies
integrates classroom-based basic science instruction outline appropriate skills for practicing physicians,
with clinical patient care. At OSUMC, students get medical students at OSUMC are trained to exhibit | 15
early clinical experience, providing patient care in them based on their level of training. The eight core
the program’s first 10 weeks, including learning to PCRS competencies include patient care, knowledge
take vital signs, give injections, draw blood, and per- for practice, practice-based learning and improve-
form electrocardiograms. Now in its seventh year, ment, interpersonal and communication skills,
this program emphasizes clinical problem-solving professionalism, systems-based practice, interpro-
in a team-based environment. fessional collaboration, and personal and professional
According to David E. Lindsey, MD, FACS, development.
department of surgery, division of trauma, critical No matter the learning style of the individual stu-
care, and burn, OSUMC, the Lead, Serve, Inspire dent, progress reports are essential for keeping the
(LSI) curriculum is intended to fortify key physi- learner on a pathway to success. The LSI curricu-
cian leadership skills, including critical thinking and lum features a student self-assessment component
knowledge synthesis. The LSI curriculum, launched with individualized education goals developed with
in 2012, took five years to design and features a feedback from faculty coaches. Evaluation is com-
three-part approach within the traditional four- petency-based, according to Dr. Lindsey, and uses
year structure. Part one emphasizes foundational multiple milestones to measure progress, and, ulti-
science; part two focuses on thematic integrated mately, help propel the student toward a categorical
clinical application of medicine (similar to third-year residency.
clerkships); and part three concentrates on advanced “What we’ve seen is a progression of our students
clinical management, including exposure to emer- to very few preliminary and many more categorical
gency medicine and advanced ambulatory care, in positions,” said Dr. Lindsey. Most U.S. medical stu-
an effort to prepare students for residency in their dents seek a categorical position, which offers funding
specialty.10,11 for full residency training. A preliminary position
“The instructor enjoys the fact that students who typically offers only a year or two of training before
are coming to them for a month on service, or wher- entering a specialty program. “The feedback from
ever they’re attending, have chosen it rather than directors across the country where our interns have
having been required to do so,” said Dr. Lindsey, who landed, as to their preparedness from day one, has
JUN 2019 BULLETIN American College of SurgeonsMEDICAL STUDENT EDUCATION
“As an educational psychologist, I can tell you
that there is no one-size-fits-all approach. I
think shifting toward a competency-based
model is, over time, the ideal approach.”
—Dr. Howley
Dr. Howley
been positive. In another six months, we’ll have data Curriculum, which is aimed at the first three years
from the American Board of Surgery In-Training Exam and is offered to students of all specialties.”
to determine how well we prepared them to begin This joint program uses simulation to help med-
their surgical training.” ical students have a uniform learning experience,
“We’re still looking at the data, but our hypoth- acquire essential surgical skills that all physicians
esis is that once a person gets a categorical residency need, and build a solid foundation for further train-
position, there will be a decrease in the people that ing.13 The simulation-based modules can be used to
change specialties,” Dr. Lindsey added. One of the teach clinical skills, ranging from taking a history
difficulties in residency is that 10 to 20 percent of the and conducting a physical, to signing out a patient,
first-year interns will decide to choose another spe- to inserting a central venous line with ultrasound
cialty. “Now, we want people to be in what they like, guidance.13
16 | but these changes can disrupt a program because A study published in the February issue of The
you then have to go through the preliminary pools American Journal of Surgery focused on whether the
and look for a replacement.” After experiencing that joint ACS/ASE curriculum could be used to teach
senior year of clinical experience in the field, it is and assess the AAMC’s core entrustable professional
anticipated that graduates will have a strong sense activities (EPAs)—13 competencies that graduating
of the residency program they want to pursue. medical students are generally expected to perform
independently.14 More specifically, core EPAs are activi-
ties that all entering residents are expected to perform
The College’s role on the first day of residency without direct supervision
“There are some challenges related to revamping or the physical presence of a supervising physician.
the fourth year of medical school,” said Susan Steine- The study suggests that the “ACS/ASE curriculum is
mann, MD, FACS, Chair, ACS Committee on Medical a viable model for implementing EPAs, particularly
Student Education. “If we really want to make that the ability to provide an oral presentation of a clini-
fourth year more specialty-based, we need to make cal encounter; give or receive a patient handover to
sure that we have ways to provide skills training transition care responsibility; and perform procedures
within the first three years and ways to assess com- (such as bag mask ventilation, venipuncture, inserting
petency,” Dr. Steinemann said. intravenous line).”14
“I think, historically, a lot of the skills necessary “This curriculum provides the students with the
for a competent physician of any specialty have been opportunity to learn these skills earlier in their medical
pigeon-holed in a surgery clerkship, and often that career and be assessed for competency earlier, so that
is not enough time to teach and assess everything,” by the time they hit their fourth year, they’re actually
Dr. Steinmann said. “As a result, the fourth year can vetted and able to perform many of the skills required
end up as a safety net to make sure that the students for a physician of any specialty,” Dr. Steinemann said.
are competent to move onto residency. The College “Both the students and the faculty will have confidence
has made some real advances in this area, specifically that they can perform a lot of these skills independently
the ACS/Association for Surgical Education (ASE) with the requisite oversight. Then that fourth year can
Medical Student Simulation-Based Surgical Skills really be focused more on patient care.”
V104 No 6 BULLETIN American College of SurgeonsMEDICAL STUDENT EDUCATION
“You can’t look at your medical student class
as a homogenous population anymore.”
—Ms. Armenia
Ms. Armenia
EPAC REFERENCES
The Education in Pediatrics Across the Continuum 1. Association of American Medical Colleges. AAMC
(EPAC) Project is another medical education model News. Press release. April 11, 2018. New research shows
rooted in competency-based progression and EPAs increasing physician shortages in both primary and
and is currently being piloted in the U.S. The goal specialty care. Available at: https://news.aamc.org/press-
releases/article/workforce_report_shortage_04112018/.
of this project is to determine whether the typical Accessed April 22, 2019.
academic pathway—from the first year of medical 2. Hartman B. The 3-year medical school: Is shorter good
school to the completion of residency—can be guided enough? Medpage Today. September 16, 2013. Available
and assessed as a comprehensive program using a at: www.medpagetoday.com/publichealthpolicy/
competency-based framework.15 medicaleducation/41651. Accessed March 27, 2019.
3. Polavarapu HV, Kulaylat AN, Sun S, Hamed O. 100 years
According to the AAMC—which is sponsor- of surgical education: The past, present, and future. Bull
ing the EPAC Project—the “prevailing structure of | 17
Am Coll Surg. 2013;98(7):22-27.
both undergraduate medical education and graduate 4. Raymond JR Sr., Kerschner JE, Hueston WJ, Maurana
medical education continues to be both time- and CA. The merits and challenges of three-year medical
tradition-based and thus at odds with a primary tenet school curricula: Time for an evidence-based discussion.
Acad Med. 2015;90(10):1318-1323.
of competency-based education, which is the attain- 5. Pathipati A. Our doctors are too educated. Washington
ment of competence by the individual learner within Post. August 13, 2018. Available at: www.washingtonpost.
their own time frame.”15 com/opinions/the-simplest-way-to-solve-our-doctor-
“The EPAC pilot is one example of a unique edu- shortage/2018/08/13/ddb344f4-91c3-11e8-9b0d-
cational innovation that could actually decelerate 749fb254bc3d_story.html. Accessed March 27, 2019.
6. Schwartz CC, Ajjarapu AS, Stamy CD, Schwinn DA.
or accelerate medical education, depending on how Comprehensive history of 3-year and accelerated U.S.
the students perform,” said Lisa Howley, PhD, senior medical school programs: A century in review. Med Educ
director of strategic initiatives and partnerships in Online. October 30, 2018. Available at: www.ncbi.nlm.
medical education, AAMC. According to Dr. Howley, nih.gov/pmc/articles/PMC6211283/. Accessed March 26,
the pilot is designed to test the feasibility of medi- 2019.
7. Cangiarella J, Gillespie C, Shea JA, Morrison G,
cal education that is based on the demonstration of Abramson SB. Accelerating medical education: A survey
defined outcomes rather than on time—from early of deans and program directors. Med Educ Online. June 13,
medical school through completion of residency. 2016. Available at: www.ncbi.nlm.nih.gov/pmc/articles/
EPAC was introduced in 2009 and enrolled its first PMC4908065/. Accessed March 26, 2019.
students in 2013 at four institutions: the University 8. Malhotra JV. Charting a new course for future physicians.
GUMC Magazine. Spring/Summer 2016. Available at:
of Minnesota School of Medicine, Minneapolis; the https://alumni.georgetown.edu/alumni-stories/gumc/
University of Colorado School of Medicine, Denver; magazine/2016/charting-new-course. Accessed March 27,
the University of Utah School of Medicine, Salt Lake 2019.
City; and the University of California San Francisco
School of Medicine.15,16 continued on next page
“As an educational psychologist, I can tell you that
there is no one-size-fits-all approach,” said Dr. Howley.
“I think shifting toward a competency-based model is,
JUN 2019 BULLETIN American College of SurgeonsMEDICAL STUDENT EDUCATION
over time, the ideal approach. In other words, it’s not REFERENCES, CONTINUED
a matter of time. It may not be four years, it may not 9. Furlong M. Moving toward a modern, student-centered
be three years—it’s how long it takes for the individ- curriculum. Faculty reflection. GUMC Magazine. Spring/
Summer 2016. Available at: https://alumni.georgetown.
ual learner to develop the confidence and competence edu/alumni-stories/gumc/magazine/2016/faculty-
to enter into residency.” reflection. Accessed March 27, 2019.
10. Abdel-Misih S, Verbeck N, Walker C, et al. Early
experience with a combined surgical and obstetrics/
Conclusion gynecology clerkship: We do get along. Am J Surg.
2018;216(5):1016-1021.
Sarah J. Armenia, MS, department of surgery, New 11. Rutan J. Lead. Serve. Inspire. Curriculum well underway.
Jersey Medical School, Rutgers Biomedical and Health The Ohio State University College of Medicine. College
Sciences, Rutgers University, Newark, NJ, surveyed of Medicine News. Available at: https://medicine.osu.
18 | 33 fourth-year medical students who had completed edu/news/archive/2012/12/31/lead-serve-inspire-
their surgery rotation to assess how medical students curriculum-well-underway.aspx. Accessed March 27,
2019.
perceive their fourth year. Most of the respondents 12. The Ohio State University College of Medicine.
(79 percent) agreed that completing a surgery curricu- Education objectives. Available at: https://medicine.osu.
lum in the final months of medical school would be edu/students/curriculum/objectives/pages/index.aspx.
beneficial before residency. Accessed March 27, 2019.
“You can’t look at your medical student class as a 13. American College of Surgeons. ACS/ASE Medical
Student Simulation-Based Surgical Skills Curriculum.
homogenous population anymore,” Ms. Armenia, a Available at: facs.org/education/program/simulation-
member of the ACS Committee on Medical Student based. Accessed March 27, 2019.
Education, said. “Tease out during your interviews 14. Steinemann S, Gardner A, Aulet T, Fitzgibbons S,
what they’re interested in because a population of stu- Campbell A, Acton R. American College of Surgeons/
dents is going to be interested in getting into this field Association for Surgical Education Medical Student
Simulation-based Surgical Skills Curriculum: Alignment
as soon as they can, and others are going to be very with entrustable professional activities. Am J Surg. 2019;
cautious and know they want to do some specialties.” 217(2):198-204.
Central to most medical school curricula modifica- 15. Association of American Medical Colleges. About EPAC.
tions is the goal of training procedurally competent Education in Pediatrics Across the Continuum (The
physicians with a more focused, student-centered EPAC Project). Available at: www.aamc.org/initiatives/
epac/about/. March 26, 2019.
approach. These modifications are thought to gener- 16. Krisberg K. Medical school in three years? Educators test
ally enhance both student and instructor satisfaction a new model. Association of American Medical Colleges.
and engagement. Medical education experts agree AAMC News. March 21, 2017. Available at: https://news.
that ongoing, evidence-based research is necessary aamc.org/medical-education/article/students-complete-
to measure the success of these programs in terms of pediatrics-program-begin-residen/. Accessed March 27,
2019.
the quality of student and graduate performance.17 ♦ 17. Murphy B. 4 phases to making goal of lifelong physician
learner a reality. American Medical Association. October
20, 2017. Available at: www.ama-assn.org/education/
accelerating-change-medical-education/4-phases-making-
goal-lifelong-physician-learner. Accessed March 27, 2019.
V104 No 6 BULLETIN American College of Surgeons2018 ACS GOVERNORS SURVEY
2018 ACS Governors Survey:
Burnout—
a growing challenge
by David Welsh,
MD, FACS;
Hiba Abdel Aziz,
MBBCh, FACS;
A
Juan C. Paramo, ccording to the Agency for Healthcare Research and
MD, FACS; Quality, the health care environment—with its packed
work days, demanding pace, time pressures, and emo-
tional intensity—can put physicians and other clinicians at
high risk for burnout. Burnout is a long-term stress reaction
marked by emotional exhaustion, depersonalization, and a | 19
Peter Andreone, diminished sense of personal accomplishment.
MD, FACS; In recent years, the rising prevalence of burnout among
clinicians (more than 50 percent in some studies) has led
David W. Butsch,
to questions regarding its effects on access to care, patient
MD, FACS; safety, and quality of care. Burned-out physicians are more
and Julian Smith, likely to leave practice, which reduces patient access to and
MB, BS, FACS continuity of care. Burnout also can threaten patient safety
and care quality, as depersonalization leads to ineffective
interactions with patients. Physicians experiencing pro-
longed fatigue also suffer from impaired attention, memory,
and executive function.
Editor’s note: The American College of Surgeons This survey revealed many causative factors for burn-
(ACS) Board of Governors (B/G) conducts an out, such as the administrative burdens associated with
electronic health records (EHRs), liability concerns, regula-
annual survey of its domestic and international
tory demands, call pressures, diminished work-life balance,
members. The purpose of the survey is to decreased compensation, lack of peer support, and exhaus-
provide a means of communicating the concerns tion. Most often, the affected physician is left with a reduced
of the Governors to the College leadership. sense of personal accomplishment. The increasing pressures
from these factors do not allow physicians the necessary
The 2018 ACS Governors Survey, conducted in
time to recover.
August 2018 by the B/G Survey Workgroup, had
a 91 percent (263/289) response rate.
One of the survey’s topics was surgeon Job satisfaction
As job dissatisfaction is often a symptom or result of burn-
burnout, and this article outlines the Governors’
out, we specifically surveyed Governors on job satisfaction
feedback on this issue. and factors associated with this state of mind. Although an
JUN 2019 BULLETIN American College of Surgeons2018 ACS GOVERNORS SURVEY
FIGURE 1.
How satisfied are
you with your
current job?
Note: Data may not add up to 100% because of rounding.
FIGURE 2.
Have you
experienced burnout
as a surgeon at any
time in your career?
20 |
overwhelming number (87 percent) of Governors satisfied (73 percent) with their jobs than their Cana-
reported they were somewhat or completely satis- dian counterparts (60 percent), and especially more
fied with their job (see Figure 1, this page), more than Governors in the U.S., only 39 percent of whom
than half (52 percent) also reported a common expe- reported satisfaction with their job.
rience of episodic burnout (see Figure 2, this page).
In their responses, Governors indicated that liability
threats, regulatory burdens, and administrative pres- Burnout
sures, combined with call requirements and poor peer Reported experiences of burnout varied greatly
support, increased overall emotional exhaustion and between men and women, with 79 percent of women
eroded time allotted for personal priorities. Governors reporting they experienced burnout in
Governors ages 55 and younger were less likely to their career versus 46 percent of men. Burnout also
be completely satisfied with their jobs (25 percent), varied greatly by age, with 77 percent of Governors
whereas Governors ages 56 and older were more likely ages 55 and younger indicating they have experienced
to be completely satisfied (57 percent). International burnout. Interestingly, all 12 Governors ages 45 and
Governors also were more likely to be completely younger have experienced burnout. In comparison,
V104 No 6 BULLETIN American College of SurgeonsYou can also read
