Cunningham and Sutton, Page Letter to (Fellow) Young Doctors: More Kairos with Less Chronos Steven C Cunningham, MD* and Erica R H Sutton, MD Department of Surgery, University of Maryland Medical Center, Baltimore, MD 21201 Invited commentary prepared for the In-Training Sounding Board of Surgical Innovation Word Count: ~3670 Key words: surgery residency; 80-hour; chronos; kairos; webcasts; DVD; teleconference; simulation; communication; technology; MASTRI; surgical curriculum; surgical education *Correspondence to: Steven C Cunningham, MD University of Maryland Medical Center Department of Surgery 22 South Greene Street, Room S4B11 Baltimore, MD, 21201 Telephone: 410-328-4089 Pager: 410-460-7817 Fax: 410-328-1012 E-mail: scunningham@smail.umaryland.edu Cunningham and Sutton, Page I Introduction In 1982, the surgeon and writer Richard Selzer wrote his masterful Letters to a Young Doctor (title inspired by Letters to a Young Poet by the German poet Rilke).1 Selzer’s Letters, in his own words, “while … entirely lacking in the genius with which Rilke’s Letters were infused, were meant to be pedagogical and comradely – a reaching out to share.” It is from that vantage point, one of comraderie and collegiality, that we share with our resident surgeon colleagues our views on doing more with less as a resident in 2008 The 80-hour work restriction has presented us residents with the following dilemma: How in this era to continue to derive the same or improved surgical experience and expertise but with less time to so? If an average surgery resident in Richard Selzer’s residency in the 1950s spent, say, 100 hours per week in the hospital and today’s resident now spends 80 hours, then the net loss of time in the hospital is >1000 hours or >40 days per year, or >200 days per five-year clinical residency The logical conclusion is that efficiency must be a key guiding principle to shape the transition For the purposes of this commentary, we will define efficiency simply as doing more with less time Ancient Greek distinguished two words for time: chronos, chronological, linear, quantitative time as measured by clocks and calendars; and kairos: qualitative time, time in relation to human activity, a moment of indeterminate duration in which something happens.2 Our efficiency goal as residents should be to gain more kairos given limited chronos In this commentary we review a wide variety of tools, both concrete and abstract, available to today’s surgical resident to maximize efficiency and effectiveness in surgical education We suggest that, irrespective of the merits or costs of current Cunningham and Sutton, Page restrictions, residents equipped with an adequate tool box and know-how should be able to benefit from as much or more kairos than was possible in the pre-80–hour, chronosunrestricted era II Concrete Tools The dictum “See one, one, teach one” represents a model of surgical heritage that embodies much that we admire in our profession In six words, it envelopes our roles as apprentice, technician and educator The phrase succinctly implies that the learner is attentive, technically efficient, and adept enough to pass to another a skill newly attained And who, with such surgical giftedness, would feel constrained by 80 hours? Realistically, we may have to observe a task a dozen or more times to recall its sequence, perform a procedure scores of times to surmount a logarithmic learning curve, and teach it repetitively to achieve mastery In the context of the 80-hour work restrictions, how can we shore up our ability to reach this goal? Using as a framework the dictum “see one, one, teach one,” we review several concrete tools that are available for trainees who seek to improve their operative skills using 21st-century technology “See One” Recalling the historical picture of the operating theater (Figure 1) we see there at the center of coliseum-style seating a patient, apprentice and master, surrounded by observers, amateur learners, witnessing at various stages of their training the privileged practice of surgery Although operating theaters are less theatrical in architectural design today, the modern operating room still may assume an ambiance of the historical Cunningham and Sutton, Page operating theater, when, for instance, a “big case” attracts an entourage of surgical residents and students to gather about the operating table, and, upon tip-toes and step-ups, observe a master surgeon perform a complex operation In 2008, however, surgery enjoys several new adjunct media through which a new audience may similarly profit The ability to perform live broadcasts from the operating room liberates the learning audience from tip-toes and step-ups We can be anywhere in the country, indeed in the world, and witness a live surgical procedure with audio commentary by the operating surgeon At our institution, for example, where the operating room has come full circle to again resemble a kind of theater – the recording studio – the surgeon may, for educational purposes, be equipped with a microphone, and the overhead surgical lighting with a camera, while a techno-tower captures, records and transmits the operation to a conference room, which may be in a nearby room – or continent There, residents may observe and interact with those in the operating room The performance of surgery is therefore now widely open for surgical resident observation in a close-up way that, ironically, was not possible years ago for observers actually present in the operating room or theater This technology has made it possible for residents to avail ourselves of a new range of tools with which to “see one”: DVD recordings of procedures for postoperative review (both for review of the master performance and for self-critique of resident performance), teleconferencing of case presentations with intraoperative video clips,3 and webcasts of procedures that are available to the public and residents alike.4 Cunningham and Sutton, Page “Do One” Concrete tools available to residents to “do one” are threefold: nonhuman simulations of treating humans, low-tech cadaveric simulations of operating on the living human body, and the traditional apprenticeship model of hands-on learning while operating on living humans under the observation of an attending surgeon The first set of tools, simulation models, is the most rapidly growing As the Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME) begins to require skills laboratories for program accreditation, this requirement is providing the administrative stimulus for development of simulation-based education in residency programs across the country Residents will thus soon be required to demonstrate competency in virtual or simulated operative environments before training in operating rooms with live patients The wide array of the tools available to 21st-century surgical residents is evidenced in many surgical simulation centers across the country and the globe For example, in the Maryland Advanced Simulation, Training, Research and Innovation (MASTRI) Center,5 four converted operating rooms (ORs) house state-of-the-art tools, including virtual reality (VR) simulators, standard mechanical trainers, and hybrid units, that allow residents to “Do One” in a simulated environment One OR provides VR endoscopic (Figure 2) and laparoscopic simulators (Figure 3), as well as multiple standard trainer workstations A second OR provides several nonhuman models for doing elective and emergent bedside procedures such as endotracheal intubation, cricothyroidotomy, central venous catheterization, and placement of chest tubes, while a third OR provides Mannequin-based simulator systems for training in medical Cunningham and Sutton, Page emergencies These tools extend the “do one” paradigm from operating skills to bedside procedural skills to medical emergency skills The fourth OR has been converted into the Cognitive and Physical Ergonomics Research Laboratory for Advanced Study of Surgical Ergonomics (Figure 4) In these operating rooms turned learning laboratories, there are new metrics to master Whereas time and number have been traditionally the most easily scrutinized measures of accomplishments and compentency (eg, completing a year of residency or a certain number of operations), we surgical trainees may in the future be increasingly evaluated on our ability to meet specific criteria (eg, achieving competency in a set of skills criteria) Such a paradigm shift in surgical education may provide a more appropriate framework for advancement through surgical training In a training laboratory, key components can be practiced repetitively without the real-life constraints of an operative case (eg, need for a patient, consent, transport, OR time, order entry) And unlike a live operation, the feedback is reliably detailed regarding the frequency with which and the extent to which precision is achieved or errors made Time and number as surrogates for surgical mastery may, to our advantage, make way for the addition of criteria-based curricula that aim to instruct trainees on precisely how to “do (the first) one.” Let us not forget that the availability of high-tech simulation tools is not mutually incompatible with the low-tech cadaver lab Quite the contrary, the dissection of fresh and preserved cadavers complements the advanced electronic simulation as a segwey to optimal preparedness for operating upon living humans As Richard Selzer has reminded us, we should “[r]eturn as often as possible to the Anatomy Laboratory As the sculptor Cunningham and Sutton, Page must gain unlimited control over his marble, the surgeon must ‘own’ the flesh… You must continue to dissect for the rest of your life To raise a flap of skin, to trace out a nerve to its place of confluence, to carry a tendon to its bony insertion, these are things of grace and beauty They are simple, nontheoretical, workaday acts which, if done again and again, will give rise to that profound sense of structure that is the birthplace of intuition.”6 Finally, the traditional apprenticeship model of hands-on learning under the tutelage of attending surgeons operating on living humans still holds an important place in the tool box of resident education The availability of simulation tools doesn’t replace hands-on operative learning, but ideally precedes, and therefore shores up and optimizes the live experience “Teach One” While the “do one” tools discussed above are also useful, after subsequent role advancement, as “teach one” tools, the act of teaching, per se, deserves special mention In his essay, The Amateur in the Operating Room: History and the Scholarship of Teaching and Learning, David Pace reminds us that “Behind every act of teaching there are two different forms of knowledge: knowledge of the subject matter, and knowledge of how it may be taught and learned.”7 While the medical field is characterized by a rapid growth in scientific knowledge, medical education, viz, knowledge of how the subject matter may best be taught and learned, has lagged in its adoption of standardized methodology and practice of teaching surgery to residents A look to the past and to the future may provide a glimpse of useful tools to come Only in 1910, after the publication Cunningham and Sutton, Page of the Carnegie Foundation Bulletin Number Four (more commonly known as the Flexner Report), was undergraduate medical education standardized Though widely criticized for its negative impact on the diversity of physician trainees, the Report did accomplish a collective set of goals and standards for American medical education A similar revolution may be expected soon to come to surgical training as well Two groups, the Surgical Skills Curriculum Task Force (developed by the Association of Program Directors in Surgery4, and the Surgical Council on Resident Education (SCORE, a voluntary consortium of six organizations with responsibility for resident education in surgery and an interest in improving the training of surgeons)10, 11 are charged with developing and implementing a national curriculum in general surgery training Future curricula produced by organizations such as APDS and SCORE will further expand the “teach one” tool box to include standardized web-based courses and learning modules Such curricula may be based on multiple organ systems divided into diseases/conditions and the teaching of specific operative skills The first web based iteration is expected to be available in July 2008 on a pilot basis to selected residency programs By the end of 2008, SCORE hopes to develop 115 modules that parallel subjects in the curriculum that will be available via website.11 III Abstract Tools The concrete tools available to today’s surgical resident, including those described above, have the potential to be powerfully effective and are rapidly improving in quantity and quality But let us not lose sight of the abstract forest for the concrete trees The forest of the pre-80–hour era was not an overgrown wasteland to be razed altogether, but a fertile Cunningham and Sutton, Page timberland that, although perhaps not renewable, produced all of the master surgeons who built and shaped our cherished and lofty discipline As Selzer puts it, “If you perceive Surgery as the loftiest branch of Medicine, remember that it is the one most vulnerable to injury and ignominy It is not the privet hedge that is uprooted in a hurricane; it is the royal palm.”12 Although when he wrote those words the 80-hour work restriction was nowhere in sight, now that it is here it may be one of the greatest threats to which surgery is vulnerable So how we preserve the soul and integrity of the surgery bequeathed to us by those who had more time to learn it? The solution, again, lies in the exchange of chronos for kairos What can we in addition to availing ourselves of the above-mentioned concrete tools? The excess time and energy that our surgical predecessors spent in the hospital we must be mindful to spend nuturing their surgical ethos, the distinguishing character, sentiment, moral nature, and guiding beliefs that tailored surgery into the discipline we chose for our life’s work Although there is nothing magical about the abstract tools we should use to this end, the new ethos of limiting residents’ time in the hospital, and the constant concern about – and difficulty in avoiding – work-hour violations could well prove sufficient to distract us from seeing those tools Because this threat, if not already realized, at least has the potential to become real, it is not fruitless to review what may seem to be an obvious set of abstract tools designed to guide us toward maintaining all the desirable aspects of the old surgical ethos The optimal outcome would of course be to have the best of the old era and the best of the new era combined in current surgical education The following tools are presented in order of pyramidal heirarchy, insofar as the development of each tool generally rests upon the base of the previous tools (Figure 5) Cunningham and Sutton, Page 10 Abstract tool #1 Attitude: Have Fun The most important tool in Surgery, as in our nonsurgical lives, may well be simply Attitude For those of us who were drawn inextricably to Surgery, this tool comes naturally, for we love our job and there is no clear line between work and play As Dr John Cameron – among others – has put it: If you love what you do, you never have to work again It is because surgery is so demanding – 80 hours or not – that the tool of Attitude, when well honed, is one of the most important; the other tools are maintained by it Increasingly as we move through surgical training we appreciate the full impact, the reorienting and grounding importance, of the simple two-word, often uttered imperitive of Dr Barbara Bass, one of our former mentors at the University of Maryland: “Have fun!” Abstract tool #2 Work Ethic: Work Hard A robust work ethic is for most of us already integral to being who we are as surgical residents Yet, as new trainees enter into surgical residencies and are cautioned, Don’t work too hard (ie, more than 80 hours per week), the potential exists for a misunderstanding of our work ethic Because unrestricted hours in the hospital devoted to mastering the art and science of surgery is no longer a luxury available (or perhaps desirable) to us, we now have to work not less hard, but harder, given the increased need for efficiency No one, as Dr John Tarpley has reminded us residents, 13 ever drowned in sweat However, sweat can taste sweet or sour, depending on our Attitude toward our work The relationship between the tools Work Ethic and Attitude Cunningham and Sutton, Page 11 can thus be characterized as symbiotic or synergistic: the degree to which we successfully wield tool #1 is directly proportional to our success with – to the taste of – tool #2 Abstract tool #3 Attention: Attend Actively As medical students advance from their preclinical to clinical years, and thence through residency, one of the most difficult apron strings to cut is that of passive learning Paying attention not passively, but actively, does not seem to come naturally for medical students, and even some residents may master this tool only late in residency This tool, like the first two, is ubiquitously employable: On rounds, team members may stand idly by paying passive polite attention, or may actively take note of what’s needed – wound supplies, data, etc – and provide it spontaneously In the OR the retracting observer may water-ski serenely through the operation, or may actively think, What’s coming next, what would I next, why was that done in just that way? Residents who are appropriately aggressive in seeking out and actively participating in operative experiences, will be rewarded with finishing residency being technically excellent young surgeons With ordered tests, the junior team member may simply check the test-ordered or result-received box, or may actively speculate, What are the possible results, and how will I respond in each case? The case of radiologic examinations warrants special mention, since in surgery, more so than in other branches of medicine, the surgeon is often better poised than the radiologist to interpret the test Active processing of results and observations is required to avoid “kneeflex rejerks.” 13 Just as the tool of Work Ethic relies on the tool of Attitude, so in a stepwise fashion does the Attention tool rely on Work Ethic Being active, not passive, keeping eyes, ears, and Cunningham and Sutton, Page 12 mind open, anticipating, certainly are all work-intensive, but are just as certainly associated with a favorable cost-benefit ratio Abstract tool #4 Ownership: Own your patients It is critical that we own our patients before leaving residency Ownership in this sense we define as personal investment in our patients, which entails compassion and love for them Although perhaps less obvious to junior residents than the first three tools, the personal investment that Ownership entails, makes natural, in a positive-feedback manner, the further honing and development of Attitude, Work Ethic, and Attention Similarly, this fourth tool and its use are again facilitated and maintained by the first three, which in themselves are not sufficient As Selzer admonishes, “It is not enough to love your work Love of work is a kind of selfindulgence You must go beyond that Better to perform endlessly, repetitiously, faithfully, the simplest tasks, like trimming the toenails of an old man By doing so, you will not say, Here I Am, but Here It Is You will not announce your love but will store it up in the bodies of your patients.”14 Interns have not had time for this kind of ownership to develop, midlevel residents may perceive it, and certainly there have been chief residents graduated without it Only after years of residency, sometimes, daresay, after years of attending, does it build A surgeon, as Selzer in an earlier work poetically put it, “does not slip from his mother’s womb with compassion smeared upon him like the drippings of his birth No easy shift of grace this, but the cumulative murmuring of the numberless wounds he has dressed, the Cunningham and Sutton, Page 13 incisions he has made, all the sores and ulcers and cavities he has touched in order to heal In the beginning it is barely audible, a whisper, as from many mouths Slowly it gathers, rises from the steaming flesh until, at last, it is a pure calling – an exclusive sound, like the cry of certain solitary birds – telling that out of the resonance between the sick man and the one who tends him there may spring that profound courtesy that the religious call Love.”15 This fourth tool, Ownership, is different from the first three in an important way: unlike the first three tools, Ownership has as its implicit focus the patient, not the resident Attitude, Work Ethic, and Attention are more akin to skills, apart from which there is little deeper meaning Ownership brings to the resident, who is ideally having fun, working hard, and attending well, a meaning; it raises the question, Does this relationship between my patients and me mean something to me? Am I personally invested? Yet, Ownership lacks something essential insofar as the meaning of Ownership is self-referential: Does this relationship mean something to me? When consideration for the meaning of surgery not to me, but to the patient, comes into play, then the we have moved beyond Ownership to Humanity Abstract tool #5 Humanity: Nurture your humanity as a resident in surgery This tool is conceptualized at the top of the pyramid (Figure 5), but, unlike previous tools, not because it requires the other four Indeed it could as well serve as the base of the hierarchy, but is placed at the Cunningham and Sutton, Page 14 top because it completes the pyramid to make it sharp and accurate much like the way a blade completes a handle to make a scalpel An empty handle can be thrust bluntly through friable tissue just as Attitude, Work Ethic, Attention, and Ownership can be thrust upon other humans (patients) without the sharp finesse of Humanity To operate upon another human is to touch them in a way that no other profession can “The flesh,” writes Selzer, “is the spirit thickened.”16 To have a disease of that flesh and to have one’s flesh opened and inspected is often a life-altering event for patients, profoundly impacting their humanity.17, 18 Indeed, the meaning that patients attribute to their disease and its surgical treatment should be eminently relevant to the surgeon, since that meaning may contribute to the patient’s psychological and physiologic response to the disease and its treatment 17, 18 The stance of the surgeon to the patient has not been compared to that a priest for naught,19 for the magnitude of the meaning that develops can be similarly great The importance of meaning in the relationship between surgeon and patient begs the question, What determines the meaning? To answer tritely, communication is everything An effective and humanistic patient encounter requires effective and humanistic communication Although a detailed discussion of what defines such communication is beyond the scope of this commentary, an ample literature on the topic exists 20 Multiple studies, including randomized clinical trials of physician-patient communication have established the positive influence of good communication on patient outcomes.21 Given that effective, civil, and frequent communication helps to preclude problems between health care professionals, so also are problems (including litigation) between professionals and patients avoided Furthermore, a healthy, trusting relationship between Cunningham and Sutton, Page 15 surgeon and patient, shored up by optimal communication, benefits not only the humanity of the patient but also, perhaps not surprisingly, that of the surgeon.22 IV Conclusion The 80-hour work restriction presents us residents with a dilemma, viz, to meet two goals, which at first glance seem mutually incompatible: To achieve the same or improved training as our predecessors, who had nearly unrestricted time, but yet to adhere to the 80-hour restrictions We suggest that that the obvious solution of increased efficiency lies in the effective employment of concrete and abstract tools The concrete tools are diverse, ranging from the most state-of-the-art simulation models to the traditional apprenticeship model, and fit the framework of the “see one, one, teach one” dictum The abstract tools of Attitude, Work Ethic, Attention, Ownership, and Humanity and, while prima facie self-evident, are potentially threatened by the need to adhere to work restrictions, and therefore deserve explicit emphasis Taken together, these tools can enable us to maximize kairos despite restricted chronos and thereby resolve the dilemma posed by the 80-hour work restrictions Cunningham and Sutton, Page 16 Figures and Legends: Figure 1: Keen clinic, surgical amphitheater, Jefferson Medical College, 10 December 1902 (Copyright © Thomas Jefferson University University Archives and Special Collections Art/Photo Collection, C1-004) [Permission requested] Cunningham and Sutton, Page 17 Figure 2: Univeristy of Maryland resident performing virtual colonoscopy using Immersion Medical’s Endoscopy AccuTouch™ endoscopic simulator in the MASTRI Center Cunningham and Sutton, Page 18 Figure 3: Virtual laparoscopic cholecystectomy shown on LapVR™ laparoscopic simulator Cunningham and Sutton, Page 19 Figure 4: The MASTRI Center’s Cognitive and Physical Ergonomics Research Laboratory for Advanced Study of Surgical Ergonomics Cunningham and Sutton, Page 20 Figure 5: A hierarchy of abstract tools to achieve more Kairos with less Chronos References ... Ergonomics Research Laboratory for Advanced Study of Surgical Ergonomics Cunningham and Sutton, Page 20 Figure 5: A hierarchy of abstract tools to achieve more Kairos with less Chronos References ...Cunningham and Sutton, Page I Introduction In 1982, the surgeon and writer Richard Selzer wrote his masterful Letters to a Young Doctor (title inspired by Letters to a Young Poet by the German... successfully wield tool #1 is directly proportional to our success with – to the taste of – tool #2 Abstract tool #3 Attention: Attend Actively As medical students advance from their preclinical to clinical