Portal de Periódicos da CAPES

How to boil a frog

2012; Lippincott Williams & Wilkins; Volume: 74; Issue: 1 Linguagem: Inglês

10.1097/ta.0b013e31827df55c

2163-0763

J. Wayne Meredith,

Primary Care and Health Outcomes

Well, thank you, Bob. What a hyperbolic, undeserved introduction but I truly appreciate it. I truly appreciate having the opportunity to serve this society. You know if you see a turtle up on a fencepost you can be pretty sure he had some help getting there. And so I want to thank some people: my senior mentors, role models, visionaries and friends, my chairman of surgery, my chairman of cardiac surgery, my first chair when I first got a job – Dick Dean – and Don Trunkey who turned me from the "dark side" of cardiac surgery to find the true love and joy of being a trauma surgeon, something which I've tried to spend the rest of my career spreading to other people; all of you people here – if it's not about your friends, I don't know what it's about. And I really must thank my incredible trauma faculty. There is just nothing that makes your life better than loving to go to work and loving the people you work with and working with people who do 110 percent gladly. It just is a joy to work with such a bright group. And, Gayle, thank you for 38 wonderful years. So the title is "Boiling the Frog." It's a — I don't know, maybe it's an aphorism. It's not a Wayne-ism. I did not come up with this. But it refers to making change happen. The adage goes, if you need to boil a frog (not exactly sure how often that comes up) but if you need to boil a frog, if you just throw the frog into hot water it will jump right out. So, you have to put that frog in tepid water and gradually turn up the heat and it won't notice it until you've boiled it. And so it's a common phrase. We have used it a lot in policy-setting type environments which means you go slowly and keep your eye on the horizon where you need to go and you build it up. So I want to talk a little bit about "boiling the frog." I want to talk about Acute Care Surgery. For those of you who didn't see some of this happening, I want to review a little on how we got here and where we are now and candidly talk about some of the obstacles that we face, and give you my suggestions as to those answers and some things that I think it's time for the AAST to consider in terms of future directions in this career. Now if you hearken back to 2000–2001, you would come to meetings like this and folks were saying "what is ever going to happen to trauma, oh, woe is me, whaaa." It was because it was a time when we were changing the way we managed patients and we were operating on them less and less. They were not as sick as they used to be. When I first became the chair of the Committee on Trauma, I looked up all the chart reviews of the site visits that had occurred to find out how much trauma surgery people were doing and at that time more than 50 percent of trauma directors in Level I trauma centers were doing fewer than 50 operative cases a year. Well, that's not enough surgery to keep you whole. It's not enough surgery to keep you good. It's not enough surgery to refill your emotional bucket. And so we were having troubles from that. So, the then president of the American Association for the Surgery of Trauma, Dr. Hoyt, and the chairman of the Committee on Trauma, convened a retreat or strategic meeting in August of '03, and included these august individuals, whose names I will not read but each of whom I will thank for their contributions to this effort, and we considered what should happen to trauma. That sort of was the question. And the outcome was we needed to change. We needed to change – and ultimately we needed to change to Acute Care Surgery. It was a very responsible group (Table 1).TABLE 1There were a lot of organizations that could have led that change. But, fundamentally that change was going to be an academic change, not other things. We felt that the AAST should be the lead society for making that change happen that we should create what is called Acute Care Surgery. We coined the phrase "Acute Care Surgery." Dr. Britt coined that phrase so that you can memorialize that. We decided to survey the constituents, identify possible programs, design a curriculum, design a mechanism for site visits, and even at that meeting recommended that we seek advisory council status with the American Board of Surgery; this being the paradigm: add trauma, surgical critical care, emergency general surgery, to create an entity called the "Acute Care Surgeon." So the AAST would take the lead. We would write a competency-based curriculum; get advisory council status; identify programs that could work, could do it, and would do it; encourage and support participation in the current critical care match; seek recognition of the specialty; work with ABS and – because at that time they had this ASA blue ribbon panel where lots of conversations were going on: are we going to change general surgery to be three core years and two specialty years? So we worked with the ABS to look at that – and lead the discussions at the AAST. From that meeting, President Feliciano appointed Jerry Jurkovich to be the chair of the first AAST committee, the goals of which were to develop a specialty that would best serve the needs of our patients; offer an attractive, viable and sustainable career and lifestyle; be recognized by the public and the profession as a valuable specialty; better define what we mean by "trauma surgeon;" and enhance the experience of current trauma surgeons. So what have we done? What have we gotten done out of that meeting in Chicago and the countless hours of dedication and work by literally hundreds of people in this room today? Well, we formed an ad hoc committee – it's had two names – 18 members, numerous volunteers helped; developed a vision of a new training program; published that vision and that plan; surveyed the membership on the plan – Tom Esposito and Jerry Jurkovich talking about is this as an attractive entity – identified and engaged organizations that opposed the specialty. We identified active support from groups and organizations that favor the specialty and identified and site visited trial programs; created a detailed curriculum for Acute Care Surgery Fellowship, following ACGME guidelines, competency-based curriculum; developed the site visit process. We built the curriculum from the ground up. So we've got to identify a body of knowledge that represents a specialty. You have to figure out a way to train people in that knowledge. You need to figure out a way to test whether or not they've gained that knowledge. And this was the first step in that. This is that curriculum. All of you are very familiar with that. I won't read it to you. And this is the current Acute Care Surgery Committee chaired by John Fildes. I will also mention Grace Rozycki who was the chair of this Committee between Dr. Jurkovich and Dr. Fildes. During that time they developed a 200 test question questionnaire examination that could be used for maintenance of certification in Acute Care Surgery and developed a site review process whereby people could go and review centers and see if their training program would work. There are now 13 programs and more on the way. I estimate we need 24 maybe, half-way there. We have renamed our journal the Journal of Trauma and Acute Care Surgery. That's a big thing. We have openly declared this is what we do. And notice on the front of your program book, "71st Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery" – another one of Dr. Britt's innovations, and the Board's innovations. We now represent not just an advisory council of the American Board of Surgery but one of the component boards of the American Board of Surgery. We had significant debate about what to call this board. We considered if we should call this the Board of Acute Care Surgery. And elected to keep – the advisory council had been named the Trauma, Burn, Critical Care Advisory Council – elected to keep the name Trauma, Burn, Critical Care Board. Those are the core components. The name of Acute Care Surgery gets commonly misused, misplaced, misidentified. Staking out the territory of Acute Care Surgery was very difficult politically to do and this leaves us an opportunity which I will come back to, to have board exams in trauma or in burns. So we elected to keep the name Trauma, Burns, Surgical Critical Care. This is the current constituency of that board. I was privileged and honored to serve as its first co-chair along with Len Jacobs. And Dr. Jurkovich has just in June become the chair of this component board and these are its current members (Table 2).TABLE 2The American Board of Surgery appoints members directly to this board who are Directors of the Board of Surgery and have an interest and an expertise in trauma, burns or critical care. We also have members elected to this board from the American Association for the Surgery of Trauma, Society of Critical Care Program Directors, AAST, again, American Burn Association, Society of Critical Care Medicine, and the Committee on Trauma of the American College of Surgeons compose the component board. Ultimately when I get to the section of this where we are talking about what do we need to do in the future, we need to think about should this board be expanded. I predict there is going to be a lot more work for this component board to do. Mostly now it gets engaged in policy decisions in terms of general surgery residency training. And it does, it conducts the critical care examination. We may need, I believe, to create some maintenance of certification work for trauma surgeons, for critical care surgeons, for acute care surgeons. That's work. There are questions to write. I think this board – I will recommend this board gets expanded. What else have we done? We have taken this year what was the Organ Injury Scoring Committee that was the committee which developed maybe the most cited papers that have ever been written by this organization which are the AIS and the Organ Injury Scaling codes, Grade V spleen, Grade IV spleen, went through all of those injuries. We've moved that committee's charge to develop disease grades for the common emergency general surgery diseases; identify the best system for measuring the physiology of those patients, where does that fit because it is timeframe essential. Just like we have anatomic injury coding for trauma, AISS or AIS scores, and physiologic measures for trauma, trauma score and other things, we need this for where we are going to go in our future research careers and our measuring quality as we go forward. Identify the best system for comorbidity measurement and identify the data needs that we will need to manage emergency general surgery with a similar philosophy and a similar approach to performance improvement and thinking about the patient first and us second that we've used throughout the career that has made trauma become a successful field and maybe one of the most advanced fields in terms of patient-centered care and quality-of-performance improvement. Dr. Shahid Shafi, whose paper you heard a few minutes ago, chairs this committee and he is ably assisted by members on this. Those of you who are young and want to get involved in the AAST, this is a great place to do that. It is important, interesting, challenging work (Table 3).TABLE 3And there is plenty of work. You are sitting in the room of an organization where people are looking for talent and they're looking for people who will work. And if you will step up you will find that your works are rewarded. The Multi-Institutional Trials Committee, chaired by Ram Nirula, has submitted a grant to the NIH for infrastructure, for data collection, and for other pieces. This could be a substantial grant if it hits – for conducting trials, data coordination. We need to focus our research agendas as the AAST on trauma, surgical critical care and emergency general surgery. And we need to focus what those agendas are and declare, strategically, what the research agenda should be that we think are the most important issues in each of these three areas. And then the MIT Committee needs to facilitate research in those areas and facilitate funding in those areas. We have commissioned a group to look at the research agenda for emergency general surgery. I do not want to steal the thunder of that group because there will be a paper here about that and a lunch session about the research agenda. We have a research agenda for trauma which was done with the CDC about seven or eight years ago. It needs to be refreshed. We have a critical care research agenda which is about 80 percent relevant to the trauma resuscitation world. We need to get those refreshed and have in our front-of-mind what is our research agenda so that we can decide on our strategy and our strategic plan and figure out where to put our resources in terms of scholarships, in terms of where to put our resources in terms of the Multi-Institutional Trials Committee, in terms of where to put our resources in terms of program, what papers go on the program. These are the things that wise, smart, forward-looking organizations have learned to do and we need to be that kind of organization – we are that kind of organization so we need to act that way. This is that group. Here are the individuals who did this (Table 4). John Morris, our vice president, ran this and did a magnificent job, in part because he is just a superbly organized and visionary individual but also because we had a lot of other really smart people in the room with lots of different backgrounds willing to do a lot of work.TABLE 4Basically, not to steal their thunder once again, we looked at health policy science, how big a health care burden is acute care, is emergency general surgery in our country. Well, there are more emergency general surgery conditions acutely diagnosed every year in this country than there are patients with diabetes diagnosed newly in this country every year. It's a big problem. It's billions of dollars of health care expenditures. We need to do the health policy science that allows us to look at the epidemiology of these conditions, what are the best practice of these conditions, what are the federal, state, local, hospital program resources that need to be applied so that we can do the kinds of things for emergency general surgery that we've done in trauma to develop robust, patient-centered, performance-improvement programs that figure out the best and the cheapest way of making these patients have the best outcome that they can be done. Obviously, we need to be looking at basic and translational research, focusing on, for emergency general surgery, those pieces of basic science that would be unique in emergency general surgery so milieus of information, best way to manage wound infection. All of those are going to be basic science topics that are important to the AAST because of trauma and because of critical care and because of other things. And there are research agendas related to that. This group is looking at finding those basic science questions that are unique to the emergency general surgery patient that are not being looked at today and obviously what do we need to do in translational research and what clinical trials are needed for us to advance this field. So we need to complete this EGS agenda. We need to refresh the trauma and surgical critical care research agendas. And they must inform our strategy and our actions as a professional society. They need to inform our budget. They need to inform our program, the program that we are listening to today. We need to inform what committees we have, what the Multi-Institutional Trials Committee group is doing and which scholarships we fund. It needs to be based on a strategy that's been thought through. Some other things that we've learned along the way — I'm going to move a little bit from the current state to what are some of our challenges and some of the lessons learned from this: surgeons, in general, need to be disease-focused not technology-focused. If you define your career by being the owner of the cardiopulmonary bypass pump or if you define your career as being the individual that does bypass grafts from the femoral artery to the popliteal artery, you are not looking at managing diseases. We need to focus on becoming surgeons who treat patients with surgical diseases. And for us that is acute care surgery. We need to focus on the disease of acute care surgery and be the experts in managing patients who have the surgical diseases of surgical critical care, the surgical disease of trauma, and the surgical diseases of emergency general surgery and not focus on what technology, define a body of knowledge; define a curriculum to learn it; develop tools to assess the competency of the trainees; develop tools to assess and approve programs; and always focus on the patients as you design your program. And we need to learn from the other specialties the things that they have learned. Learn from vascular surgery be disease focused. They have revolutionized their approach because they treat patients with vascular disease, not just treat patients with proline and GORE-TEX and saphenous veins. We need to learn from the CT surgeons where are your referring physicians and keep a broad base of referring physicians into our practices. We need to learn from emergency medicine to fill the vacuum, right, which there is a vacuum rapidly forming in this country of an inadequate supply of surgeons willing to work in our communities, our small towns, our small hospitals who will take care of sick patients in the middle of the night who have emergency general surgery problems. We need to fill that vacuum. We need to learn from EDP's in the negative to focus on the patient, not on the shift, as we retrain our residents to work in an 80-hour world. And we need to learn from them to treat things definitively. We do not want to create a training program where we are training people to be the least-qualified physician in a hospital to do a set of things. We need to treat diseases where we are the most-qualified physician to treat those diseases. That means learn to treat the things we treat definitively and be the best at it in our hospital, not do those things where we are barely adequate and scratching our way into it. And we need to learn from neurosurgery and pediatric surgery the laws of supply and demand. We have had turf issues with orthopaedic surgery, neurosurgery, both of whom somehow felt like we were going to create this field and create all these hoards of hosts of acute care surgeons who were going to start fixing every fracture in the country, start evacuating every epidural hematoma. And I think to the extent to which that violates the principle of we should do those things which we are the best in the hospital to do, we should not do that. Now, there are circumstances where we are the best in the hospital to do certain things and in that case we need to rise to the occasion. You know, we need to be trained well enough to do it. But we need to not do that. The other field I want to talk about most is general surgery programs. These are folks who are afraid that we are training for their specialty. We are not training for your specialty. We are training for acute care surgery. We are not training people to have experience in liver surgery so that they can do liver resections for cancer because treating patients who need a liver resection for cancer is about treating a disease state which is cancer. And the technology that is necessary to treat that disease is just a part of treating that disease. The disease we treat is trauma. The disease we treat is emergency general surgery. And the principles of managing those patients, the principles of attacking the problem of the disease state is much broader than being able to do the operation; that's why we have to be full doctors to do the work that we do. So we are not going to be thinking about or training surgeons in acute care surgery residencies to do liver resection surgeries. We need them to go train in liver resection surgery as simulation training. It's a giant, high biofidelity simulator for trauma surgeons. When you think about it, there are common anatomy, common exposures and common techniques that trauma surgeons need to know in terms of operating on the liver. And the time to learn those as a trainee is not with a .357 magnum hole that you can fit a Coca-cola can in down the middle of the liver. Your resident is not going to get to do as much of that case. You need to learn that anatomy and you need to learn to manage those vessels and you need to learn to manage the liver in a controlled environment where there is time and you can talk and you can see and you can learn how to do it slowly so that when the time comes that you need to do it under fire, that part of the operation you have learned. It's just like learning in a simulator. We need to learn these techniques in a controlled environment. Now, I would argue that an individual who understands trauma and understands resuscitation and understands the principles of managing patients with urgent, acute, life-threatening, going-to-die-tonight-if-we-don't-fix-it problems, those people who have these common anatomy exposures and techniques are better able to manage that patient with a Pepsi-cola-sized hole through their liver than someone who only performs that work electively. It's – I think acute care surgeons are better able to do that and are the people who should do it. In order to make that happen we must be learning the techniques needed to repair these injuries. But it's not about training for your specialty; it's about training for ours. I talk to general surgeons a lot and I struggle with this. I identify with this question. They say, well, when you describe to me what acute care surgery is you're just describing general surgery. And I believed that for a long time but I've come to realize that's not true. Acute care surgery is not general surgery. It's a damned important part of general surgery. It's a damned important part of general surgery that we need to make sure our general surgery residents are trained very well in. But acute care surgery is not doing breast biopsies and elective hiatal hernias and symptomatic gallbladders and screening colonoscopy. We're not doing general surgery. General surgery is a lot of things. It's a broad, open, glorious field. We should be proud and enriched to be a part of it. But we're just a part of it and we're not in competition with it. We're supporting it, and here is why. Most residents today in most of the training programs in this country are not being exposed to as many general, true general surgeons in the context that the champions of this philosophy think about. They're not being exposed to many of those. There are many programs where residents are not exposed to any. They are exposed to master surgeons, surgeons who are incredibly technically skilled, have an amazing, intuitive sense of the disease that they treat and how that affects their patients and what it takes to get them through. There are amazing people like that. But they are not teaching residents to master the art of emergency general surgery because they hate emergency general surgery. They hate it. So, what do our residents learn? Our residents learn from the guys and gals that they admire, from their Don Trunkey, the people that they look up to and want to be like. They get a call and say, "Hey, I've got this great patient in the emergency room. He's got a ruptured pancreas." And they go, "Oh, crap. Do I have to come do that?" They hate it. We need to train our residents just like we train them in breast surgery, by people who specialize and are interested in breast surgery, that get up every morning thinking about breast cancer, that think about randomized controlled trials about breast cancer, that think about cosmetic results in breast cancer. They think about how to talk to patients and tell them what operations they need for breast cancer or colorectal cancer or vascular disease or heart disease or lung cancer. We need people training our residents in emergency general surgery and trauma who think like that. And when we do that our trainees will want to do it. Over half of the residents in our program at Wake Forest University are going into trauma and going into acute care surgery now because – well, I showed you our faculty. They are vibrant. They love this stuff. They teach it. They are having fun every day. And the residents and medical students look at it and go, that looks great to me. That's how we get students and residents interested in our field. But, more importantly, or as importantly, those residents who finish and decide they want to practice broad general surgery, they want to do a lot of endoscopy in the office, and gallbladders and hernias, they think of emergency surgery as the fun part of a practice. They've got all this work to do but when they get a nice case – Dr. Lucas told me when I was wet-behind-my-ears, going on our first site visit – he said trauma surgery is your – "You are married to general surgery; trauma surgery is your mistress. It's the thing you do for fun on the side." I know that he doesn't actually have a mistress. I don't want to start any rumors from the podium but as an analogy it's right. That means that people get out, they finish, they do general surgery, they love their chance to do trauma. They love their chance to do emergency surgery because we teach them about it. And we need to teach them about it. Very few programs train residents today with faculty who see emergency general surgery (EGS) as their field, as their principle academic career and their principle interest. And this is the secret to getting enough general surgeons to cover the emergency surgery call in our country. We'll never train enough to do it. So they are saying, do not take our business from breast surgery, endoscopy. Preston Miller, who is in the audience, Bess Wildman, Vice-chair for Business, Mike Chang, and I studied the results when we changed from a trauma service to an acute care surgery service and the real question was amongst those surgeons who were doing surgical oncology and transplant and minimally-invasive surgery and a full spectrum of general surgery at a major academic medical center, they were concerned that we were going to starve them out. But, in fact, they had more collections after we went to emergency general surgery. And the collections improved, so did the emergency general surgery and so did the acute care surgeons. Their work RVUs decreased slightly and their collections increased. The payor mix improved. Their lifestyle improved. They could do more cases because if you're not getting interrupted by the pancreatitis you admitted on Sunday and you have to do that Monday, Tuesday and Thursday, you can get more Whipples done and you get more liver resections done and you get more colon resections done. I do not believe ACS is a legitimate threat to the livelihoods and the practices of people who want to do elective surgery in a large hospital in a big place where there is enough room for those people and in a place where there is room for more emergency general surgery to be brought in. There is some generalization questions about this study because it is at a major academic medical center and I am not sure that it translates to your Wilcox Hospital here on this island; pretty sure it does not. I checked them out lately. It might not work for them. But it does work for that. This cannot be an exclusive specialty. The mental model that would say we are going to go and train acute care surgeons and we are going to cover and train enough acute care surgeons to populate the world with surgeons who will manage all the emergency general surgery conditions; I do not think that is going to happen. This is not totally recent but the trends are exactly the same. This is the American Board of Surgery Diplomates for Vascular Surgery Qualifying Exam and Surgical Critical Care Qualifying Exam to fit into an Acute Care Surgery program: you have to work at a Level I trauma center; you have to have a Surgical Critical Care Fellowship program. We have about the same number of training programs as vascular. We have about the same number of graduates, actually fewer, than vascular. We are not going to ever be big enough to be training people like this. These are the surgery certifying exam: 1,200 – ten times the number. This is not going to be a specialty. But something is needed to be done. And this is a great study to look up from the Royal College of Surgeons in England which was a sort of an expose, if you will, Flexner report, IOM-type report looking at the results of emergency surgery in their country. And they really, it shows how important it is to get organized and to do that. I used this quote to support it. Jerry Jurkovich, one of my heroes in life, "The acute care surgeon specialist will be filling a niche which is rapidly becoming a void in the provision of acute surgical care to the American public. The field of trauma surgery will benefit from these changes. The individuals who will benefit most are our patients." That's why we do this. The IOM report, you know, came out, recommended that we regionalize emergency care, heart, stroke, stemi, emergency general surgery, trauma. Obviously the model we believe, we would all believe, is the trauma group getting on the right direction here. This is their model, that different hospitals would have regionalization and different things. This is not centralization. This is not sending them all to a major medical center. This is regionalization where there is a plan and everybody is a part of the plan and everybody has a role in the plan. I think the trauma system is the best model upon which to base the proper acute care surgery system. I think the services will work in large hospitals like trauma services do but the network of all the hospitals together providing coordinating care, performing performance improvement together, like we do in trauma systems, looking at protocols, looking at best practices, teaching one another, learning from one another, and helping one another is the way to do it. And the accountable care organization movement is going to facilitate and reward us for doing this. And I believe, for the first time in our lifetimes, that that could actually happen. I will give you one caveat. If you think about all the things that cascaded from the time that we started this concept of trauma systems, that began at the Level I, what ultimately became the Level I trauma centers, the urban, hardcore trauma centers. And the movement was designed to identify – if you think back to the optimal resources for care of injured patients' document was a tool to identify what is needed in the Level I-type trauma center from hospital administration, from the staff, to provide those resources. And it grew from Level I and then realized it needed to be made inclusive and grow out from Level I to Level III. I think as we think through how to begin to build and do the pieces for an emergency general surgery analog of that we need to start at the Level III or maybe IV and build this system in. The system and the resources and all the pieces that are necessary to take care of these emergency general surgery patients already exist in our major trauma centers. They already exist in our safety net hospitals. The place where they are suffering, the place where they need someone like the American College of Surgeons or us to come to their rescue, to help define the resources, to help define the process, that's in the small rural community. We need to help them find surgeons that will do it. We need to help them find the data. We need to help them have operating rooms when they need them. We need to have coverage by anesthesia and other specialties and define what those needs are and how they get done. And we need to have the surgeons paid to take that call. And we need to be out there advocating for that. And I think we will be foolhardy if we think of regionalization of this starting in the Level I-type hospitals; we need to start out there where they need the help now. And then the last piece I want to talk about, I think it's time for the American Association for the Surgery of Trauma to start thinking about what would it be like should we, what are the pros and cons of, and to start to "boil the frog" to have the debate, to sort through, should we create a new board with a new examination and a new board certificate. In order to do that, according to the ACGME, there needs to be an existence of a body of knowledge that is distinct and detailed – we have that; sufficiently large group of physicians – look around. There are a lot more than there are sleep specialists getting certified today. The existence of national medical societies with journals and regular academic meetings – look around. The regular presence at academic units – we have those all over the country now. Sufficient number of projected programs – I would argue that we do. We definitely need to have our sights set on making sure we have that number. Minimum duration of one year of training – that's the Acute Care Surgery Fellowship is there. No adverse impact on the primary specialty – our Acute Care Surgery Committee assures that before they will certify a program. Trauma meets all of these. Now, that raises the question what would be the next step? Should there be an acute care surgery board? And I, personally, would recommend that we start thinking through the thought process that an acute care surgeon is an individual who is triple boarded. The acute care surgeon is an individual who is triple-boarded and trained in emergency and general surgery, uses that subset of, that broad base of knowledge and that subset of emergency general surgical techniques in emergency general surgery cases, is boarded in surgical critical care and is boarded in trauma. That would open up some opportunities for us that I think might help. But at any rate we need to begin the debate. We need to think about this. I, personally, think we must have general surgery boards to do it. And I think the board will require that. Plus-minus whether you should have to have critical care boards to do a trauma board fellowship. I have my biases on that. I think we should. There are some other really tough issues in this debate, though, and it's going to take some time and it's going to take some reasoned heads to help think it through and then "boil the frog." For instance, right now it is really important to our current training programs in acute care surgery that these individuals work out, they are working on their own. And the way the programs are funded, the way their hours are managed, off-duty hours, all the pieces that the ACGME accreditation applies profoundly influences the way you can do the training and the way you can organize the training program. We have to sort through all that. And then who will we grandfather? There are basically three strategies for grandfathering: grandfather no one at all. The surgical oncology group has just done this and they have created a board of advanced surgical oncology, grandfathered no one. That's an acceptable way of doing it. The vascular board grandfathered a few special people. It turned out bad. It turned out to be a major problem with the vascular board, the Board of Surgery. The other option is to grandfather liberally, much like we did in surgical critical care. I will be a proponent of that though I am not sure that I know all of the issues and all of the pieces. And the argument to grandfather no one has merit. But I think we need enough people interested in doing trauma care across this country that we would let people stand up. And, frankly, I think as a general surgeon, as someone who has dedicated his life to the profession of surgery, I think I would be embarrassed by how few people signed up to grandfather in trauma care. But I think they ought to have the chance. And I think they ought to be able to prove they have the knowledge and they ought to be boarded in that. So, this is my father. You heard Bob talk about him a little bit. I heard in the locker room one night the anesthesiologist saying "man, I am inspired. I am hopeful that I can live my whole career and be as happy as old Jess Meredith who is about 70, about 70 weeks from retirement. And I hope I can enjoy my career my whole career." I asked my Dad the next time I saw him, "How do you do that?" And he said, "It's easy; never lose sight of why you started this work in the first place. And it is easy to get dragged away from that." So let's face this future. Let's accept the inevitable but in so doing let's not lose the values that got us here in the first place.