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Presidential address: Generations apart—bridging the generational divide in vascular surgery

2003; Elsevier BV; Volume: 38; Issue: 6 Linguagem: Inglês

10.1016/j.jvs.2003.07.024

1097-6809

Anton N. Sidawy,

Primary Care and Health Outcomes

It is with humility and great honor that I stand before you today as the President of the Eastern Vascular Society. This Society has a very special place in my heart. I have been associated with the Eastern Vascular Society since its inception, and I have attended every one of its seventeen annual meetings. From my association with the Eastern Vascular I have gained much more than knowledge in cutting-edge techniques, useful clinical studies, and intriguing scientific observations. I have developed relationships, friendships, and a sense of belonging that I have enjoyed greatly and that I will treasure for years to come. The Eastern Vascular Society was founded in 1987 by leaders of vascular surgery on the East Coast of the United States, and rapidly became the largest regional society in terms of total membership. Many of the founders of the Eastern Vascular became presidents of the Society, colleagues I consider mentors and role models. The experience and hard work of these national leaders and their established groups provided an immediate source of excellent clinical and scientific presentations that played an essential role in the continued success of our annual meeting. We still maintain the original format of high-quality presentations followed by discussions informal enough to allow any member or attendee to discuss a paper or present his or her experience, a situation that many find awkward in the forum of a meeting of a national society. I do not think anyone highlighted the importance of such a discourse better than William Osler did in the Maryland Medical Journal in 1897: No class of men needs friction so much as physicians…The daily round of a busy practitioner tends to develop an egoism of a most intense kind, to which there is no antidote. The few setbacks are forgotten, the mistakes are often buried, and 10 years of successful work tend to make a man touchy, dogmatic, intolerant of correction, and abominably self-centered. To this mental attitude the Medical Society is the best corrective, and a man misses a good part of his education who does not get knocked about a bit by his colleagues in discussions and criticisms. This society represents such a forum—a forum that encourages informal discussion to provide a milieu in which senior members interact in a spirit of friendship and collegiality, and a forum in which excitement in the art and science of vascular surgery encourages excellence and originality for our junior members. This interaction provides the “corrective” for the “intense egoism” that Osler so eloquently described, and the excitement and optimism about vascular surgery that we should be conveying to our junior members, students, and residents. Perhaps nothing threatens access to competent vascular care more than our inability to recruit highly qualified medical students and residents who are interested in the care of vascular disease. Patient, system, and physician factors determine access to health care. Although I have strong opinions regarding the effects of patient-specific and system-specific factors, I will limit my comments today to physician-specific factors. It is not a secret that in the last few years the interest of medical students in surgery and surgical subspecialties has waned. The lay press is starting to take notice; an article entitled “Surgery: not cutting it,” in Newsweek, summarized this problem and its possible causes.1Carmichael M. Surgery: not cutting it. Newsweek, 25 May 2002Google Scholar Although this article accurately identified important factors in the decline of the appeal of surgery, the surgeon's lifestyle and the inability of surgery to attract female medical students ranked high on the list. Before analyzing these factors (Table I) in the hope of formulating remedies, it is important to examine the projected need for vascular surgeons and whether the current number of graduating vascular trainees is enough to satisfy that need.Table IProposed factors that discourage medical students from considering surgery and its specialities1. Lifestyle issues2. Inability to attract women to vascular surgery3. Diminished reimbursement4. Malpractice crisis5. Long residency and debt accumulation6. Active efforts to discourage medical students from entering surgery Open table in a new tab Dr James Stanley and his Committee on Workforce Issues of The Society for Vascular Surgery and The American Association for Vascular Surgery (SVS/AAVS) have done excellent work projecting the need for vascular surgeons that will exist 30 years from now. Although many factors influence such projections, publications by this committee provide a good idea of the need for well-trained vascular surgeons in the years to come.2Stanley J.C. Barnes R.W. Ernst C.B. Hertzer N.R. Mannick J.A. Moore W.S. Vascular surgery in the United States workforce issues. Report of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery, North American Chapter, Committee on Workforce Issues.J Vasc Surg. 1996; 23: 172-181Abstract Full Text PDF PubMed Scopus (100) Google Scholar, 3Stanley J.C. The changing vascular surgery workforce.Semin Vasc Surg. 1997; 10: 65-71PubMed Google Scholar, 4Stanley J.C. Presidential address The American Board of Vascular Surgery.J Vasc Surg. 1998; 27: 195-202Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar And the picture is not pretty. From population projections by the US Census Bureau, 5Sixty-five plus in America. In: US Bureau of the Census. Current population reports: special studies. Washington, DC: US Department of Commerce; 1993. p 23-178Google Scholar, 6Statistical abstract of the United States. In: US Bureau of the Census. Current population reports. 114th edition. Washington, DC: US Department of Commerce; 1994Google Scholar the effect of Baby Boomers becomes apparent in 2020 to 2030. The total population of the US in 2030 is estimated to swell to 350 million persons, of which 107.6 million (30.7%) will be 55 years or older and 70.2 million (20.1%) will be 65 years or older. This is an increase of 73% in the elderly population. In contrast, the population under 65 years is expected to decrease by 3%.2Stanley J.C. Barnes R.W. Ernst C.B. Hertzer N.R. Mannick J.A. Moore W.S. Vascular surgery in the United States workforce issues. Report of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery, North American Chapter, Committee on Workforce Issues.J Vasc Surg. 1996; 23: 172-181Abstract Full Text PDF PubMed Scopus (100) Google Scholar At the 2002 SVS/AAVS meeting Dr Stanley presented the most recent projections for the vascular surgery workforce for 2030 (J. C. Stanley, personal communication, 2002). Taking into consideration the expected explosion in the US population, 1,683,500 vascular interventions will be performed, of which 1,198,450 (70%) are expected to be operative. If vascular surgeons are to perform only 75% of these operative interventions (assuming 25% will continue to be performed by non-vascular surgery-trained surgeons), they will perform 898,838 operations. If we assume that a vascular surgeon will be performing on average 200 operations a year, it is estimated we will need 4,494 trained vascular surgeons. To meet this demand in 2030 we have to graduate about 160 vascular residents per year, starting now (J. C. Stanley, personal communication, 2002). The difficulty of accomplishing the task of training and graduating more residents to satisfy future needs becomes more evident when we consider the barriers vascular residency programs are finding in filling their currently approved positions with US medical graduates. The 2003 vascular surgery match results (for residents' appointment year 2004) are quite telling.7National Resident Matching Program. 2003 Match results. Available at: www.nrmp.orgGoogle Scholar There were 88 active vascular residency programs offering 103 positions. Ninety-one (88%) positions were filled through the match, leaving 11 (13%) programs and 12 (12%) positions unfilled. Analysis of the composition of the applicant pool is more telling; 108 applicants remained active in the application process. Eighty-nine of these applicants (82%) matched. Of the 108 active applicants, only 81 were US graduates. Therefore, in the 2003 match process, 81 US medical graduates were vying for 103 positions, a situation even worse than the 2002 match, where 84 US graduates were competing for 98 positions8National Resident Matching Program. 2002 Match results. Available at: www.nrmp.orgGoogle Scholar (Table II). This highlights the main obstacle organized vascular surgery is facing when it tries, not only to increase the number of training positions needed to meet the demand, but even to fill the currently available positions with qualified US graduates. There are just not enough takers!Table IIComparison of 2002 and 2003 vascular surgery match results2002 Match∗National Resident Matching Program. 2002 Match results. Available at: www.nrmp.org.2003 Match†National Resident Matching Program. 2003 Match results. Available at: www.nrmp.org.No.%No.%Active programs8788Programs filled78887788Active positions98103Positions filled by all applicants89919188Total active applicants108108Active US graduates8481Matched US graduates7472Active positions filled with US graduates74/987572/10370∗ National Resident Matching Program. 2002 Match results. Available at: www.nrmp.org.† National Resident Matching Program. 2003 Match results. Available at: www.nrmp.org. Open table in a new tab Since vascular surgery derives its applicants from the surgical resident pool, it would be prudent to consider the ability of general surgery to attract qualified applicants. In a way, with the current vascular surgery training paradigm, our interests and those of surgery are intertwined. Any discussion of the recruitment issues facing vascular surgery should include the performance of general surgery in that regard. Where did we, or for that matter, where did surgery, go wrong? In an attempt to delineate the reasons for our inability to recruit more of the best and the brightest, a survey of medical students regarding interest in vascular surgery was conducted by the Issues Committee of the Association of Program Directors of Vascular Surgery (K. Calligaro, personal communication, 2002). When asked about reasons that made vascular surgery unappealing as a specialty, 82% of medical students cited the lifestyle of surgery residents and 72% cited the lifestyle of vascular surgeons as negative factors (Table III). Table IIIMedical student survey of Association of Program Directors in Vascular Surgery: Answers to the statement “Reasons vascular surgery not appealing”Important (%)Not important (%)Lifestyle as general surgery resident8210Lifestyle as surgeon729Negative mentors5523Poor quality rotation4738Length of training4525Patients “too sick”4232Too much debt2852From K. Calligaro, personal communication, 2002. Open table in a new tab From K. Calligaro, personal communication, 2002. Women are more affected by lifestyle issues than men are, and we are doing little to attract them. Although women represent 50% of the available talent in the graduating medical school class,9Barzansky B. Jonas H.S. Etzel S.I. Educational programs in US medical schools, 1999-2000.JAMA. 2000; 284: 1114-1120Crossref PubMed Scopus (67) Google Scholar, 10Barzansky B. Jonas H.S. Etzel S.I. Educational programs in US medical schools, 1998-1999.JAMA. 1999; 282: 840-846Crossref PubMed Scopus (52) Google Scholar only 9.6% of active vascular fellows in the academic year 2001-2002 were women; and if we exclude obstetrics and gynecology, which traditionally attracts more women, only about 20% of surgical residents are women. And in our Eastern Vascular Society, only 3.4% of the members are women. Currently only two (2%) vascular surgery program directors are women. Female students do not identify with surgery. In an earlier paper entitled “Surgery—still an old boys club,” Lillemoe et al11Lillemoe K.D. Ahrendt G.M. Yeo C.J. Herlong H.F. Cameron J.L. Surgery still an “old boys' club”?.Surgery. 1994; 116: 255-259PubMed Google Scholar found that more than 90% of female students at Johns Hopkins perceived surgery to be unfavorable to their gender and felt “out of place” on the surgical service, whereas 0% of male students did. Clearly, the attitude of male residents toward female medical students is a very important factor, since graduating male residents do not encourage female students to choose surgery as a specialty.12Mayer K.L. Perez R.V. Ho H.S. Factors affecting choice of surgical residency training program.J Surg Res. 2001; 98: 71-75Abstract Full Text PDF PubMed Scopus (83) Google Scholar Women are given the impression that surgery is not favorable to their gender, especially if they want to have a family and raise their children. In fact, starting a family is one of the major issues that play a role in discouraging women from entering surgery and surgical specialties. Mayer et al13Mayer K.L. Ho H.S. Goodnight Jr, J.E. Childbearing and child care in surgery.Arch Surg. 2001; 136: 649-655Crossref PubMed Scopus (87) Google Scholar surveyed graduating surgical residents over an 11-year period. Although there was no difference in their age at graduation, 64% of men and only 15% of women had children during residency. This difference carried over to the years after graduation, when 95% of men and 40% of women had children.13Mayer K.L. Ho H.S. Goodnight Jr, J.E. Childbearing and child care in surgery.Arch Surg. 2001; 136: 649-655Crossref PubMed Scopus (87) Google Scholar In addition, and for a good reason, women tend to take more time off than men do after the birth of their children. No doubt this is viewed by some as placing hardship on fellow residents or practice partners. We need a complete change in attitude toward female medical students rotating on our services. Vascular surgery cannot afford to exclude from consideration almost 50% of the available talent graduating from medical schools. I do not want to give the impression that lifestyle issues are only important to female medical students; male students also consider these issues as they are making a decision regarding career choices. With the change in family structure and the increase in the rate of families with two working spouses, men and women have been sharing family responsibilities. In turn this is attracting more men to specialties with a controllable lifestyle. As I emphasize the lifestyle of surgical residents and surgeons, I do not mean to diminish the effect of other equally important factors. Surgeons' income has been eroding over the years; however, the public remains unsympathetic to our plight, because reports in the lay press and readily available information on the Internet continue to emphasize that the income of physicians tops the list of all professionals. On the surgical service medical students are continuously bombarded by negative messages, such as decreasing reimbursement for surgical procedures and the ever-escalating malpractice insurance premiums. These concerns are further emphasized when they hear that even established surgeons are turning away from surgery, as indicated by the ever-decreasing retirement age of surgeons, which is now at 58.5 years for fellows of the American College of Surgeons (P. E. Collicott, personal communication, 2003). Increased indebtedness, compounded by declining reimbursement for surgical specialties, is playing an important role in medical students' decision to not want to lengthen their postgraduate training years. It is not unusual for medical students to have about $100,000 of debt on graduation. The debt will undergo more compounding with the number of training years after graduation from medical school. As reported by Woodworth et al,14Woodworth P.A. Chang F.C. Helmer S.D. Debt and other influences on career choices among surgical and primary care residents in a community-based hospital system.Am J Surg. 2000; 180: 570-575Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar the anticipation of debt of more than $100,000 was a significant factor for primary care residents in choosing that field. The length of residency, desirable lifestyle, and working hours were also more important to individuals who chose primary care. Debt reduction for residents entering surgery is very important, and can be accomplished with innovative methods, not the least of which is a change in salary structure. Innovative loans can be structured, resulting in considerable savings on student loan payments. The Association of American Medical Colleges and Sallie Mae introduced earlier this year the MEDLOANS Consolidation program, which allows eligible borrowers to lower their monthly student loan payments by up to 50% or more.15New loan program helps medical students manage education debt. The Assocation of American Medical Colleges; 2003. Available at: www.aamc.orgGoogle Scholar New paradigms in vascular training may address the length of training problem. Although 3+3 and 4+2 paradigms have been proposed, the American Board of Surgery and the Residency Review Committee for Surgery approved the 4+2 paradigm in February 2003, with qualified institutions to recruit candidates as early as July 2004. Under this pilot program, which is referred to as the Early Specialization Program, dual certification in surgery and vascular surgery is preserved, as approved by the American Board of Medical Specialties. However, the enthusiasm of vascular surgery program directors toward this initiative has been limited, because of the stringent requirements placed on programs willing to take advantage of it. In addition, this paradigm shortens the training period by only 1 year. Is that going to be enough to result in a significant effect on the attitude of applicants and attract them to our specialty? That remains to be seen; however, this is a step in the right direction. Medical students have been discouraged from pursuing surgery by an overzealous drive to produce more generalist physicians. Over the years there has been a concern that organized medicine has been producing far more specialists than needed, especially when compared with the number of generalists and family practice physicians, contributing to the paucity of preventive medicine and the spiraling cost of health care in the United States due to the perception that specialists tend to perform more expensive diagnostic and therapeutic procedures that may or may not be necessary.16Schroeder S.A. Sandy L.G. Specialty distribution of U.S. physicians the invisible driver of health care costs.N Engl J Med. 1993; 328: 961-963Crossref PubMed Scopus (71) Google Scholar This concern is not new. As far back as 1895, Stedman17Stedman C.E. The profession as viewed by the public.Boston Med Surg J. 1895; 133: 177-182Crossref Google Scholar expressed his concerns regarding this issue in the Boston Medical Surgical Journal by stating that “specialists are squeezing out family doctors as vines do to the trees.” However, this issue was brought to the forefront in 1981 when the Graduate Medical Education National Advisory Committee18Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services. DHHS publ no. (HRA)81-652. Washington, DC: Department of Health and Human Services; 1981Google Scholar predicted that there would be a surplus of specialists in the United States. The Council on Graduate Medical Education19Council on Graduate Medical EducationReport III. Improving access to health care through physician workforce reform. Department of Health and Human Services, Washington, DC1994Google Scholar embraced this concept, and popularized the notion that there would be 100,000 to 165,000 too many specialists by 2000, and proposed increasing the ratio of generalists to specialists to result in a fifty-fifty split. Although this concept and the methods used to derive it were challenged by many,20Schwartz W.B. Sloan F.A. Mendelson D.N. Why there will be little or no physician surplus between now and the year 2000.N Engl J Med. 1988; 318: 892-897Crossref PubMed Scopus (62) Google Scholar, 21Cooper R.A. There's a shortage of specialists is anyone listening?.Acad Med. 2002; 77: 761-766Crossref PubMed Scopus (81) Google Scholar, 22Cooper R.A. Seeking a balanced physician workforce for the 21st century.JAMA. 1994; 272: 680-687Crossref PubMed Scopus (134) Google Scholar it gained momentum, and efforts to limit the number of specialists continued. Some medical schools have decreased the third-year surgical rotation to a total of 6 weeks and changed the subspecialties rotation, including vascular surgery, to a fourth-year elective.23Hundert E.M. Dannefer E.F. Double helix curriculum. University of Rochester School of Medicine and Dentistry, Rochester, NY1997Google Scholar This, in effect, almost eliminates the exposure of medical students to vascular surgery at an early stage in their medical education. Furthermore, many enthusiastic supporters of the move to limit specialization used many tactics to encourage medical students to enter primary care. One of these tactics has been to emphasize the controlled lifestyle of the generalist physician, especially compared with that of the surgeon. For the generation from which we are attempting to attract surgical candidates, manageable and controlled lifestyle is a most important feature in planning career choices, and ranks as high as, or sometimes higher than, income and type of job. Although I have summarized reasons usually proposed for our difficulties in recruiting an adequate number of highly qualified physicians to our specialty, I would like to emphasize that to figure out solutions to this problem we should not see the trend as explainable and thus acceptable. We must seek other reasons for our inability to attract more of the best and the brightest to our specialty. Are we even connecting with those students we are attempting to attract? How can our generation connect with theirs? What differences are there between the two generations: ours, the Baby Boomers, and theirs, Generation X? The Baby Boomers (or simply Boomers) were born between 1946 and 1959, give or take 5 years. As a group they value work, power building, and leadership. They are not technologically savvy. In addition, they believe in chain of command and in loyalty to hierarchy.24Recruiting and retaining cross-generational membership. Wilmette, Ill: CareerStrategies; 2000. p 1-4Google Scholar Generation X members (Gen-Xers, or simply Xers) were born after 1965. The media gave them this descriptive name because they are the tenth generation to come of age in the twentieth century.24Recruiting and retaining cross-generational membership. Wilmette, Ill: CareerStrategies; 2000. p 1-4Google Scholar Xers are 40 million to 50 million strong, with more than 1 trillion dollars in buying power; therefore, they are targeted by advertisers and marketers. The Washington Post identified the Xers’ vote as one of the key factors in electing President Clinton, who was able to attract members of this generation by appearing on “MTV,” and playing the saxophone, donning his sunglasses.25Tulgan B. Managing Generation X. W. W. Norton, New York, NY2000Google Scholar Organizations have had to deal with conflict between Boomers and Xers, mainly because Boomers' interpretations of Xers' behavior and attitudes are shaped, in one way or another, by their own biases.25Tulgan B. Managing Generation X. W. W. Norton, New York, NY2000Google Scholar Is our attitude in surgery shaped by “Boomer” mentality, so that we are unable to connect with Xers and therefore unable to attract them to our ranks? Surgery is not the only institution that has had to deal with diminished enrollment of members of this generation. The US Army has had the same problem with junior officer attrition. The Army tried all traditional fixes, including pay raises and improved retirement benefits, to no avail.26Wong L. Generations apart Xers and Boomers in the Officer Corps. Strategic Studies Institute, US Army War College, Carlisle, Pa2000: 1-30Google Scholar Leonard Wong, from the Strategic Studies Institute of the US Army War College, has written a comprehensive report examining the role of the generational divide on junior officer attrition, in the hope of formulating solutions to reverse the trend.26Wong L. Generations apart Xers and Boomers in the Officer Corps. Strategic Studies Institute, US Army War College, Carlisle, Pa2000: 1-30Google Scholar While reading Wong's report I could not help but draw similarities to the difficulties faced by the Army and those faced by vascular surgery in recruiting junior members to their ranks. Although the two generations are quite different from each other (Table IV), the life and experiences of Baby Boomers shaped the characteristics of Generation-X. Boomers were born into traditional family structure, in which their fathers worked and their mothers stayed at home to take care of the family. They grew up in times of perceived prosperity, and their parents and society had high hopes for them. They were goal-oriented, hard workers, and driven to succeed. They worked hard, not only to provide for their family, but “work was a goal in and of itself.” Furthermore, the sheer number of Baby Boomers encouraged teamwork and cooperation; their numbers overwhelmed the school system, and they had to learn to work well with others. In addition, women entered the workforce, and it was not unusual for a Boomer family to have both spouses working. Divorce was common in Boomer families.27Zill N, Robinson J. The Generation X difference. Am Demogr 1995;24-33Google ScholarTable IVCharacteristics of Baby Boomers and Generation-X membersBaby BoomersGeneration-XBorn between 1946 and 1959Born after 1965Born into traditional family structureMany lived in single-parent homeTeamworkIndependent and confidentValue work, and driven to succeedReacted to parents' “workaholic” lifestyle“Work is a goal in and of itself”“Work only important to have a life”Goal-orientedNeed to have clear missionNot technologically savvyTechnologically savvyLoyal to hierarchyNot impressed by hierarchyFrom Tulgan B. Managing Generation X: how to bring out the best in young talent. New York, NY: W. W. Norton; 2000; Wong L. Generations apart: Xers and Boomers in the Officer Corps. Carlisle, Pa: Strategic Studies Institute, US Army War College; 2000. p 1-30. Open table in a new tab From Tulgan B. Managing Generation X: how to bring out the best in young talent. New York, NY: W. W. Norton; 2000; Wong L. Generations apart: Xers and Boomers in the Officer Corps. Carlisle, Pa: Strategic Studies Institute, US Army War College; 2000. p 1-30. These factors led Xers to spend time alone nurturing their self-reliance, independence, and confidence. That does not mean that Xers are not team players; however, to be loyal to the team they need to have a clear mission, because Xers believe that a team without a mission is unlikely to produce valuable results.25Tulgan B. Managing Generation X. W. W. Norton, New York, NY2000Google Scholar In reaction to their Boomer parents' workaholic lifestyle, Xers sought a more comfortable balance in their life, allowing for time to spend with their families and friends. For Xers, work is not a goal in and of itself; rather it is a means for them to “have a life.”26Wong L. Generations apart Xers and Boomers in the Officer Corps. Strategic Studies Institute, US Army War College, Carlisle, Pa2000: 1-30Google Scholar These factors influenced medical career choices of Xers. As learners, technology shaped this generation. They are technologically savvy, with computers being part of their life. They process information quickly, and have the ability to multitask. They are visually oriented, and assimilate information better when it is illustrated and presented in a simple manner. They are eager to learn, and they entered college in record numbers. They learn better from real-life examples, not from didactic conferences. Members of this generation do not learn well under pressure; information should be presented in an entertaining manner. Although they crave feedback, they hate being micromanaged. To the surprise of their Boomer parents, organizations have adapted to their ways; in the workplace they demanded, and were granted, work conditions that suited them, such as flexible work hours and telecommuting. The surgical community has not adjusted to these conditions. Surgery lagged behind in accommodating members of Generation X. Our Baby Boomer generation continued in surgery with business as usual. We continue to project the image of the surgeon as macho and willing to work endless hours, missing important family moments such as a child's soccer game or ballet rehearsal. The medical students rotating on the surgical service are expected to also work long hours, and if they exhibit their generational characteristics of preferring a more controlled lifestyle, we give them the impression that they are not suited for a surgical career. Furthermore, we have been very negative in our opinion of this “generation of students and residents,” because they do not conform to our customary image of the surgical resident. Xers do not tolerate being undervalued; if they sense that, they are quick to look for the exit. Boomers usually misunderstand this characteristic, and label members of Generation-X as disloyal.25Tulgan B. Mana