Presidential Address

Abstract

The arterial switch operation is now the procedure of choice for babies presenting with transposition of the great arteries. Recent experience documents that this operation can be performed safely for all coronary artery anatomic variations with very low operative mortality. This procedure should be offered to all babies presenting with this otherwise fatal condition. Expectations for operative survival are now approaching 100%.

The past few years have visited enormous changes on surgical departments in academic medical centers. While many positive aspects of academic surgical practice have occurred, rapid changes have created an atmosphere of uncertainty in many teaching faculties. Declining reimbursement, large increases in malpractice premiums, and the need for greater accountability and direct supervision in all aspects of patient care have placed enormous financial burdens on academic departments, as indeed, they have in all of surgical practice. Declining student interest in surgery and the resident work hours restrictions have left surgeons uncertain about their own fate and that of their discipline. Most of these problems have been well described in presidential addresses and various publications.^1–5 What has not been well-documented, in my opinion, is the impact these changes and other factors have had on surgical departments.

It is my goal to examine the current status of our academic surgical departments in the South with an aim of providing a view of their strengths, weaknesses, and current health based on a detailed survey of these units. An academic department was defined as one that trained general surgery residents.

METHODS OF SURVEY

An interview was conducted with senior surgeons regarding the status of their department. When possible, the chair of the department was interviewed as well as another senior surgeon within the department. Institutions with general surgery residency programs were obtained from the Handbook on Accredited Residency programs published by the Accreditation Council for Graduate Medical Education (ACGME). These programs are listed by states, and those with a clear geographic connection to the South or with senior members who have been active participants in the Southern Surgical Association were chosen for interview. Letters outlining the purpose of the survey and a request for participation were sent. Interviews were conducted over a 7-month period from April to October 2003.

The interview was done in a one-on-one informal manner in person, or most commonly, by telephone. All surveys were conducted by the author. A survey instrument was developed to ensure that comparable pertinent information was obtained from all interviewees. Interviews that included details of financial information lasted an average of 70 minutes (range, 50 to 110 minutes). Those of other faculty took an average of 35 minutes (range, 25 to 65 minutes).

The survey focused on 6 major areas, with numerous subcategories in each section. The sections included (1) faculty issues including the chair and (2) financial matters that related to departmental health. Detailed information was also requested on 4 major aspects of most academic departments: (1) student teaching, (2) resident training, (3) clinical care, and (4) research. Faculty members were asked to rank their program on a 1 to 10 scale (10 being the highest) on these items. Strengths and weaknesses were reviewed, and the overall health of the department was assessed by the interviewees. Many open-ended questions were asked as well.

All interviewees were assured of the confidentiality of department information. The potential limitations of this survey are notable. The survey was developed by the author alone and could be biased. There was no means to document the veracity or accuracy of the responses. The interview technique required spontaneous replies to some queries that might have been answered differently with further time and reflection. Those interviewed were all relatively senior in terms of academic rank. There was a preponderance of general surgeons interviewed and a few cardiac surgeons and plastic surgeons but no other specialists. However, the variance in scoring was consistent with apparently objective evaluations, and the responses were generally consistent between different faculty members within departments.

SURVEY RESULTS

Interviews were conducted with 75 surgeons representing 54 departments (Table 1). Forty-six were chairs of university departments or chiefs of training programs at non-university departments. Twenty-nine were vice-chairs, program directors, or other senior surgeons. The programs surveyed constituted over 95% of program in this region. Forty-five departments were based at universities, and 9 were training programs not based at a medical school.

TABLE 1. Institutions Surveyed

TABLE 1. continued

FACULTY

The average university-based Department of Surgery has 43 paid full-time faculty members, with a range of 7 to 125 (Table 2). Most faculties have had considerable increases in their size in the past 5 years, and only 3 departments report faculty contraction. The use of part-time paid faculty has declined in most institutions, although 17 university departments still have at least 1 part-time paid faculty member.

TABLE 2. Number of Full-Time University Surgical Faculty

The average paid or full-time attending surgeons in non–university-based surgical training programs is 12, with a range of 3 to 24. Even in these so-called “private programs,” the number of “full-time” faculty is increasing, although these programs generally rely much more heavily on nonpaid, volunteer attending physicians.

CHAIRS

The chairs of surgery in this region are currently nearly filled, with only 1 acting chief identified at the time of the survey. The average chair has been in that position for 6.8 years (range, 6 months to 32 years). Eleven chairs have been in place for 2 years or less. Only 2 have tenure greater than 20 years. Most chairs are in general surgery-based disciplines, while a few are cardiac surgeons. Fifty-three are men and 1 is a woman. The chairs interviewed were remarkably consistent in their view of challenges faced, primarily predicated on budgetary restraints. Several chairs commented on the difficulties inherent in the expectations that they could be responsible for behavior of faculty members and residents in matters that often had little, if anything, to do with surgery.

In response to the query, “What is the biggest mistake a chair can make?,” 2 responses dominated the survey. The first was related to difficult interactions with the dean or administrative officer. Even relatively new chairs often related examples of extremely unpleasant interactions with superiors involving a variety of issues (but usually focused on money); an apparent lack of collegiality with administration was often present. The additional “major mistake” noted by chairs was a poor choice in a faculty member. Over 80% of chairs listed a “bad hire” or some variant thereof as the worst administrative error they could make or had made. Nearly every chair with more than a few years tenure recounted a difficult experience with faculty who did not fit the system, did not deliver services as promised, were unable to build clinical services, or had unrecognized personal or personality problems. Litigation by disgruntled faculty was mentioned by several chairs as a problem during their tenure. High levels of compensation for new recruits above those of existing faculty was stated as a frequent cause of friction within departments.

Non-chairs interviewed were queried as to the most important attributes of the chair. The attributes believed most important were people skills, fairness, administrative ability, and basic fiscal knowledge/skill. Only 1 person interviewed mentioned the necessity to be “clinically active.” No respondent mentioned surgical skill, being a good doctor or clinical leader, good scholar, or surgical scientist!

Although faculties are increasing in size, many departments have experienced significant faculty turnover in the past 5 years. Nearly every department has lost at least 1 key department member to private practice. Forty percent of departments have turned at least half of their faculty in the past 5 years. On the other hand, there are some departments that have experienced little faculty loss.

As previously noted, recruiting is a major issue for current surgery department leadership, and almost all departments were actively recruiting at least 1 faculty member. Many of the replacement faculty are being recruited from the institution's own resident ranks or the local community. This phenomenon of high turnover and internal recruiting has created much more junior faculties in many institutions. The average faculty rank of 10 selected programs (Fig. 1) demonstrates a large base of junior faculty, smaller number of associate professors, and a slightly larger number of professors.

FIGURE 1. Distribution of faculty by academic rank. The graphs represent an average of 10 departments of approximately 40 faculty members. Note the proportion of junior faculty and fewer associate professors.

Many departments report major difficulties in the recruitment of senior faculty for key roles within the department. When chairs were asked the question, “Could your department recruit a senior associate professor or professor level from another institution to lead an important program within the department,” 60% responded “no” or “with great difficulty.”

Even those who responded affirmatively noted that the funding for such an endeavor would require support from the dean or hospital. The length of such extradepartmental support was never longer than 3 years and generally was only 1 to 2 years. Several institutions had been able to attract funding for endowed chairs for faculty recruitment, but even in these circumstances significant additional resources were needed for faculty salaries. Virtually no department reported that they had been able to obtain new, recurrent salaries for additional faculty. Similarly, “recruiting packages” for the purposes of several simultaneous faculty appointments was deemed impossible by 90% surveyed, unless they were replacing departed faculty. Even in circumstances of replacing faculty departures, simultaneous appointments were difficult.

The forces that have pulled (or driven) specialty disciplines from the general surgery-based core department continue. Many departments now consist only of disciplines related to general surgery (Fig. 2). Plastic surgery and cardiothoracic surgery are often part of the core department, but only a handful include otolaryngology, neurosurgery, or orthopedics. Myriad organizational structures exist within departments in the South with little commonality, except for the overwhelming tendency for small disciplinary units (eg, trauma, vascular, colorectal, GI, etc.) to be increasingly independent of colleagues from a financial perspective.

FIGURE 2. Surgical “departments” often include cardiac and plastic surgery, but uncommonly contain other disciplines.

In those departments that included surgical subspecialties (eg, orthopedics, urology), chairs were asked whether this was a positive aspect of their faculty interactions. Half felt having continued specialty presence was positive because of increased departmental influence with the dean or hospital. Half felt it was problematic because of issues in recruiting or retaining the surgical specialists.

The ratings for faculty morale were extremely variable (ranging on the numerical scale from 2 to 9). Perhaps not surprisingly, chairs tended to rate morale somewhat higher than nonchairs (average 1.5 points on a scale of 1 to 10). Departments with new chairs tended to rank morale somewhat higher. Infusion of new resources and a sense of invigoration were commonly cited themes when new chairs had been hired. The difference in the tones of the discussion in these departments with high versus low morale was palpable. Usually, these issues were due to limitation of resources, but the duty hours restrictions of residents was cited as frequently as financial issues for poor faculty morale. Clearly, faculty feel they are working harder, more often without students and residents, and are often unhappy with this situation. An additional frequently cited condition of morale problems related to volatility or lack of stability within faculties. Uncertainties engendered by lack of financial control of one's destiny and faculty turnover were frequently mentioned factors for low morale. Contrarily, departments with good morale mentioned fairness (“all in the same boat”), openness, and a good working relationship with the department chair, dean, and hospital as crucial.

Only general information on salaries was requested. The standard response was an attempt to reach or maintain the American Association of Medical College (AAMC) 50^th percentile benchmark. Interestingly, many departments with high and low morale appeared to have similar income structures, suggesting non-monetary factors are frequently involved.

SURGICAL DEPARTMENT FINANCES

There is enormous variation in the surgical department budgets in the South ranging, from 2 to 120 million dollars. The average budget of the 45 university programs was 25 million dollars. Seven departments had a budget less than 5 million dollars, and 6 had annual incomes of greater than 50 million dollars. The sources of revenues vary depending on the nature of the institution and the size of the surgery department. Three small departments received the majority of their funding from the university or their state government. However, the remainder generated most of their income from clinical practice.

The percent of the 2002 budget derived from practice income in university departments ranged from less that 10% to 92%. On average, over 70% of departmental income was derived from clinical practice. In several large departments with major research funding, the percentage of income derived from practice was lower, despite large clinical incomes, due to the infusion of research dollars. Twenty-two university-based department chairs (46%) reported that practice income contributed about 80% of their 2002 budget.

Three of the 9 non-university programs reported that practice income accounted for more than 80% of their budget. The other programs of this type had fewer full-time faculty and less demands for clinical income to finance educational activities. Invariably, faculty growth was financed almost exclusively from practice income, whether in university or non-university teaching positions.

When departmental chairs were asked to describe their funding mechanism, most stressed the absolute requirement for active clinical surgeons with busy practices. If research was being conducted, a strong funding source was mandatory. Virtually no non-funded or poorly funded research occurs for faculty beyond their first years on the faculty. Chairs reiterated that practice incentives for faculty were the rule. In most departments, clinical productivity, usually based on some variant of the Relative Value Units (RVU) system, was the primary basis for faculty compensation rather than academic rank or other faculty attributes. Some departments had bonuses for activities such as teaching or scholarship, but clinical productivity seemed to be the preeminent virtue of the current academicians in Southern surgical departments. Over half of the chairs reported their departments had made personnel changes (ie, forced resignations, retirements) or major salary reductions because of productivity issues.

A curious phenomenon, which was presumed to be a product of Southern culture, occurred frequently in the chairs’ description of their departments’ finances. Fourteen chairs spontaneously described their financial model as “eat what you kill!” This undoubtedly harkens to the hunting and agrarian roots common in our region. In such a model, it is presumed that faculty will, in essence, through their clinical practice provide their own income (or most of it). Financial models were discussed with 16 chairs from the New England area and Pacific Coast, and none mentioned “eat what you kill.” This is a statistically significant difference, with a P value less than 0.007 with a Fisher exact test. Dr. Thomas Gadacz, the Chair from Medical College of Georgia, offered this corollary to the self-financing model: “our model is that one eats some of what they kill (not all), but if they don't kill something, they won't eat anything!”

One of those who frequently shares in the income generated by surgical faculty is the medical school dean. Forty-one of 45 university programs have a dean's tax. Four had additional direct taxes for university presidents or chancellors, although other deans apparently shared with university presidents as well. In 2 of the 4 departments without a tax, the dean had the authority to usurp funds as needed for central administrative costs. Deans’ taxes were extremely variable, ranging from 2% to 20%. In some situations, departments received obvious benefits from this taxation in the form of practice space, faculty development funds, malpractice premium payment, or the like, but in many there was little direct benefit from this tariff. Finances within departments were so variable that no pattern could be discerned.

The majority of departments had a similar list of financial problems. The predominant problem was the need to provide large amounts of indigent care; over 70% of departments had a large segment of the population who were medically indigent or underfunded. Trauma care was frequently cited as a major financial drain on departments. Nearly every department in a state-supported university experienced a budget cut in the past year.

Medical liability coverage has emerged as a problem for many departments in the South. Most departments had experienced a 50% to 100% premium increase in the past 2 years. Public institutions in Florida, Texas, and South Carolina had not experienced such problems because of sovereign immunity exemption. State institutions in Louisiana had premiums paid by the state. Many large faculties and hospitals were self-insured. However, even those with seemingly huge reserves often required large payments into the reserve funds. Several chairs opined that self-insurance programs had become another form of central taxation, as layers of hospital vice-presidents and associate deans had portions of their salaries covered by the faculty malpractice premiums.

On the positive side, most surgery departments do not believe they are directly subsidizing other departments as was the case in the past. Thirty-one chairs (69%) believe their administrative superior (whether dean or hospital CEO) had realistic or reasonable financial expectations from the surgery department. Interestingly, most of those who felt their dean had unrealistic financial expectations had serious fiscal problems in their department.

Twenty-one of the 45 departments stated they had positive reserves or retained earnings in department accounts (defined as spendable, liquid assets); these ranged from less than 1 million to 17 million dollars. (Table 3). Five departments had deficits up to 5 million dollars owed to universities, hospitals, or banks. Nineteen had neither deficits nor reserves. Several chairs noted that acquisition of reserves was not healthy because these accounts could be appropriated by deans for other purposes. Several chairs reported their departments had lost millions of dollars from reserve accounts that had been commandeered by their university administration.

TABLE 3. Reserves and Deficits

STUDENT TEACHING

The average third year student clerkship on surgery was 8 weeks (80% of institutions). The distinct minority had a requirement for a fourth year surgical rotation. Almost all surgical departments felt there were inherent problems with their ability to effectively teach students about surgery. These include (1) lack of early preclinical exposure to students; (2) inadequate length of rotations; (3) heavy clinical load for faculty, which detracted from teaching duties; (4) inadequate funding for teaching; and (5) a forced primary care emphasis within the school.

Nearly all departments felt they had improved their student teaching program within the past 3 years. In response to the national decline in interest in general surgery careers, 42 of 45 departments had made changes in their approach to student surgical education within the past 3 years. Changes included creation of surgery clubs or interest groups, informal student sessions with chairs and senior faculty, student dinners and picnics, sponsorship of surgical conference attendance, and other enrichment activities for students.

The aims of these efforts often had little direct relationship to didactic experiences for students. Rather than changing lectures, most were directed at improving the image of surgical departments with students and efforts to enhance the attractiveness of surgical disciplines as a career. Although it is difficult to quantitate the early success of these efforts, many faculty report unprecedented student interest in surgical careers among their students. Most believe this interest relates to their department's recruitment efforts rather than change in resident work hours.

Despite the faculty perception of a better student experience on surgical rotations, most felt there was still room for improvement. The most common rating given by faculty for student teaching was 7 (average of 7.3) (Fig. 3). Areas where surgical faculty felt they needed to improve included better lecture attendance, improvement in bedside clinical teaching, and broadening the teaching base from 1 or 2 “designated” teachers per department.

FIGURE 3. Faculty ranked their departments’ student teaching an average grade of 7.

The other clear trend expressed by many faculty was the absolute need to recruit their own students. Recruitment of an institution's own students decreases the possibility of deficiencies in the match and sends a strong message to students from other schools about a program's attractiveness. Many faculty noted they were less likely to encourage student visits to other programs than in the past.

RESIDENT TRAINING

The average general surgical residency in a university-based program in the South has 5.3 trainees (range, 2 to 13). For those non-university programs, the range is 2 to 8 trainees (average, 3.7). The majority of residency programs are pleased with the quality of residents they are attracting to their programs. Only 4 chairs expressed disappointment with their recent resident recruits. Three program directors from non-university programs were concerned about the quantity of applicants because they had no student class from which to attract resident candidates. Several noted the tendency of university-based programs to “hold their own students more tightly”.

The resident work hours restrictions have created many problems for surgical departments in terms of both education and service commitments. The attitude of faculty was one of overwhelming desire for compliance with both the spirit and letter of the ACGME mandate on work hours. Concerns about work hours restrictions centered on issues of continuity of care and potential lack of concern for the patient. Almost every respondent felt that their already overextended faculty was now working even harder. Several chairs noted that faculty were often forced to staff clinics for indigent patients alone, despite the fact that the justification for having these activities was ostensibly for student and resident education. Several programs had ended valuable rotations, particularly outside university hospitals, because of workforce constraints.

Several faculty felt very positively about the duty hours policies, noting that with proper organization of rotations and schedules no adverse outcomes on patient care or education should occur. Furthermore, the improved lifestyle for residents was believed contributory to increased attractiveness of surgery as a career choice. Several chairs noted an increased interest in preliminary training by residents in anesthesia or emergency medicine after the duty restrictions were in effect.

Virtually all those interviewed were highly enthusiastic about the quality of surgical training for residents provided by their department. Ninety percent rated their residency program 8 or higher (Fig. 4). Likewise, a strong residency program was frequently cited as 1 of the 2 leading attributes when detailing strengths of a department.

FIGURE 4. Resident training was ranked an average of 8.1, with most faculty extremely satisfied with their programs.

CLINICAL CARE

The other attribute invariably noted as a departmental strength was the excellence of the clinical program (Fig. 5). Academic departments in the South usually have multiple hospitals involved in the teaching programs, with a mean of nearly 4 hospitals per program. However, as previously noted, work hours restrictions were creating pressures on hospital affiliations. Strong alliances and effective partnerships with affiliated teaching hospitals were noted as a major strength of most programs that were financially strong. Only 3 programs had a solitary teaching hospital.

FIGURE 5. Clinical care was scored very highly by virtually all respondents (average 8.4).

Veterans Administration (VA) hospitals were a part of 28 programs. The VA hospitals, which were once an indispensable component in many institutions, were now often viewed as a mixed blessing. Only 10 departments described their relationships with their VA hospital as good or healthy or strongly positive. Ten characterized the relationship as mixed, while 8 regarded it as unhealthy or more negative than positive. Two programs were strongly considering ending their relationship with the VA. On the positive side, most programs felt the VA hospitals provided residents with an opportunity to care for patients with more autonomy than in other training venues. Many residents had a patient experience that complemented training received at other hospitals. Several chairs cited the positive financial benefits of VA affiliations, particularly for young faculty members, and the opportunity to receive untaxed (by deans) income.

VA hospital affiliations had major disadvantages for many departments. The most frequently cited problem was the onerous nature of documenting faculty adherence to their assigned time commitment. Secondly, a few VA hospitals have altered their role such that they functioned more as outpatient centers than tertiary hospitals, obviating much of their value for resident training. Thirdly, several departments were concerned about the quality of care provided and inefficiencies within VA hospitals. Many departments supplemented salaries of VA faculty, creating additional cash flow problems. Relatively few VA faculty were utilizing the Merit Review Funding System for investigations (see research below).

There were 2 observations noted by the essayist regarding the VA and academic department relationships. First, relationships between the VA and departments seemed more harmonious when VA faculty were full-time at that institution. Secondly, there appeared to be enormous differences in the way rules for faculty were interpreted in various institutions. Some departments reported enormous problems, while others noted none with apparently similar faculty coverage arrangements.

Respondents noted large volumes of patients in the primary teaching hospitals, particularly in complex care. Training programs invariably contain a variety of surgeons specializing in an area that has traditionally been under the umbrella of “general surgery.” Most programs had nearly all of the general surgery specialties (Fig. 6). Of note, programs were more likely to have a surgical oncologist or vascular surgeon than a broad-based general surgeon, and nearly all had a surgeon dedicated to trauma and critical care. Dedicated transplant and bariatric surgeons were present in 83% and 81%, respectively, and were as common as broad-based general surgeons. Many departments had multiple surgeons involved in these specialty practices, but in some the myriad specialties contributed to the perceived lack of depth at a faculty level.

FIGURE 6. Most departments had general surgery-based specialty representation. Broad-based general surgeons were no more prevalent than transplant surgeons.

The clinical care provided by academic surgical departments in the South was rated as a 9 or 10 by 70% of those interviewed (mean, 8.7). In those rated lower than 9, the reason uniformly cited was the lack of a specialty program rather than the inherent quality of an existing program.

RESEARCH

Unlike student teaching, residency training, and clinical care, where there was the appearance of considerable uniformity of opinions about programs in the South, thoughts about research efforts were widely varied. Twenty-nine of the university departments had faculty who did bench research, while 16 departments did not. National Institutes of Health (NIH) grants were present in 27 departments. The difference in scope of funded research ranged from 1 faculty grant in a department to some of the largest research units in the country. In several departments who had faculty with NIH grants, these faculty members held a PhD rather than an MD degree. Only 9 institutions had faculty members with VA grants (out of 28 with a VA hospital).

Nearly every university-based program in the South reported an increased institutional emphasis on bench research within the past 5 years. Even relatively new medical schools formed to train primary care doctors now have deans and presidents who desire to build research institutions. Two common themes emerged from these interviews: (1) almost all surgery departments exist in schools that desire to be a “research university,” and (2) no fewer than 13 departments are in universities that desire to be in the top 10 in research funding for their medical school! Many schools are making enormous commitments of financial resources to attract new faculty who have large grants or to build new infrastructure for research. The funding for these projects is often supported either directly or indirectly from clinical dollars.

The majority of those departments with NIH funding do not participate meaningfully in the indirect costs recovery program to the university. In over 80% of departments, none of the “indirects” return to the department, even though many believe they are departmentally funding costs that should be covered. In the small number of departments who participate in the indirect cost recovery, research seems to be particularly strong because of the sharing in the rewards for their efforts.

All chairs were queried about “protected time” for faculty with an expectation to do bench research. About one third of departments had a formal mechanism for “protected time.” However, chairs admitted it was often extremely difficult to encourage/force young faculty out of the operating room and into the laboratory, even when there were financial incentives to do so. To quote 1 chair: “I can give income protection but cannot padlock the operating room doors.” Some chairs stated that “protected time” was a “myth” and that faculty must organize and prioritize their time commitment individually. One chair offered “protected time” from “6:00 pm to midnight and every weekend.” It was noteworthy that despite the alleged increased emphasis on research, many departments currently provide no funding for travel or meeting attendance.

Interviewees were asked whether their institutions’ increased emphasis on research had benefited the department of surgery. Responses were extremely varied from enthusiastically affirmative to no difference positively or negatively to a resounding “no.” Chairs and other senior faculty often disagreed strongly on their department's research emphasis. Chairs generally supported efforts to improve research funding more strongly than nonchairs. Those who advocated the value of strong research programs noted the many positive benefits such efforts afforded their department: (1) increased prestige; (2) improved recruiting of bright, young faculty; (3) a scientific training ground for residents and fellows; and (4) the opportunity for the creation of new knowledge. Many excellent research institutions are in our region, and the prestige of their work inures to the good of their department and university. Dr. Hiram Polk of Louisville noted that surgery departments must be involved in cutting-edge bench research that is competitively funded: “Departments not engaged in such research run the great risk of being treated as second-class citizens both within their institution and nationally.”

No surgeon interviewed was anti-research, but many felt it was being disproportionately emphasized and often funded at the expense of clinical programs. Examples of inequities cited included diverting funds from hospitals and clinical programs to fund bench research or build research buildings, reallocation of funds from clinical to research faculty, appropriation of surgical department reserve funds for a research building, and the like. Many chairs and faculty in departments without a strong research tradition feared their institution was on a “perilous course” (as described by one chair) in its attempt to become a “major research university” because of funding required to build a research program. Individually, surgeons were often frustrated by their perceptions of a “double standard” of rewards within universities, with clinicians work unappreciated and researchers rewarded in terms of issues such as promotions, tenure, compensation, and recognition.

Even in departments that are successful at securing funding for research, there are often enormous pressures. Numerous interviewees noted that to spend 1 million dollars of research funding, a department needs an additional $250,000 for other associated expenses. Such funding is increasingly difficult to accrue. One chair commented only half in jest: “First prize in the research game is a million dollars, second is 5 million, and third is ten!”

Many surgeons feel frustrated by the nature of research within their departments, which is often conducted by PhDs who, it is felt, collaborate little with clinicians. Many surgeons seem frustrated that molecular biology projects may be funded but not endeavors that are inherently surgical in nature. As one chair noted: “Laparoscopic and endovascular techniques have revolutionized patients’ lives but would have never had any chance of being funded as research endeavors at their inception.”

Productivity in clinical research and traditional clinical scholarly activity seems to be declining in many institutions. Increased demands on faculty time and decreased rewards for non-funded scholarship are reasons noted for this decline. Scholarly activity was also being focused into narrow specialty interest groups rather than into broad-based surgical groups.

Faculty rated the bench research in their department from 0 to 10 (Fig. 7), with a mean of 6.5 notably lower than the other areas rated. Likewise, clinical research and scholarship unrelated to bench laboratory work rated 6.4.

FIGURE 7. Faculty ranking of their departments’ basic research differed widely in comparison to teaching, resident training, and clinical care.

NON–UNIVERSITY-AFFILIATED PROGRAMS

Nine programs were training general surgical residents in programs without a major direct university umbrella for their training. All of these programs appeared to have strong residency training. Student teaching and bench research were generally not concerns and allowed these programs to focus on the provision of strong clinical care and residency training. Seven of the 9 interviewed appeared to be doing well, while 2 were experiencing financial difficulties that potentially imperiled their academic missions. Those faculty interviewed in the remaining 7 programs seemed to be among the most professionally satisfied respondents interviewed in this survey, and they rated the health of their department higher.

CURRENT STATUS OF ACADEMIC SURGERY DEPARTMENTS

Despite the fact that many departments noted myriad financial and organizational problems, few felt their school or department was in jeopardy of closing their doors. Faculty of 3 university programs and 2 non-university ones felt their programs had this potential unless financial problems were solved. Poor financial situations at the primary teaching hospital were the central issue in these cases. The remainder graded their departmental health as an average of 7 (range, 2 to 9) (Fig. 8). However, many noted the enormous difficulty in attempting to balance the 4 academic missions (student teaching, resident training, clinical care, research) and the pervasive sense of foreboding engendered by difficult financial situations. As Dr. Phillip Burns of Chattanooga stated: “I would rate our current health as an 8, but we are only 1 bad financial quarter from rating a 3.”

FIGURE 8. The ranking of the health of the department had a bell-shaped curve distribution (average, 6.7).

COMMENTARY

Faculty in departments in the South were often large, especially when one considers that many surgical specialties had independent departments that were not counted. Despite their size, faculties often had 3 problems noted: (1) members were often very junior, (2) there was a lack of depth in many of the general surgery specialty areas; and (3) faculty (chairs and non-chairs alike) felt they were overworked. The lack of midlevel and senior faculty in some departments appeared to be directly related to reimbursement policies. Several chairs noted senior faculty had been encouraged to leave or chose to leave because of financial pressures, but their departure had created a void in mentoring or performing departmental or hospital tasks for which no compensation was received.

The large number of specialties represented within general surgery often contributed to the perceived lack of depth. Even though most departments had representation in the every general surgical specialty, this often might consist of only one surgeon. The tendency to have small economic subunits in colorectal, trauma, vascular, laparoscopy, etc. has accentuated this sense of lack of depth. As 1 chair noted, “we have all general surgery interest areas filled, but most have only 1 person. We are like a skeleton with no muscle.” On the other hand, several departments have multiple surgeons within narrow interest groups creating the critical mass needed for productive patient care, resident teaching, and research. As in other areas, the dichotomy in faculty depth between successful departments and those doing less well was striking.

Faculties of the future may be much more inbred than those of the past. First, the majority of junior faculty are coming directly from the institution's resident ranks. Secondly, most departments noted they were often unable to compete for senior faculty outside the institution due to financial constraints. Finally, chairs noted the worst administrative mistake they could make was a “bad hire,” and many related disastrous examples to illustrate this point. Each of these factors have a potential chilling effect on out-of-institution recruiting that almost certainly will result in more inbred faculties. Several chairs noted that junior faculty from their institutions were often excellent young surgeons, but frequently were not committed to an academic career and left the department after a few years, creating further turnover.

The income generated from clinical practice, both in total dollars and as a percentage of the entire budget, is huge. One could argue that the use of practice income to pay surgeons’ salaries is only logical. However, most departments cover myriad expenses from practice income that are primarily related to education and training, rather than clinical efforts per se. Academic secretarial support, compliance officers, student and resident coordinators, resident travel, and occasionally resident and fellow salaries may be funded wholly or in part by clinical income. In the past, one could argue that residents were such tremendous assets to faculty, that shifting of clinical income to training efforts was justified on purely economic grounds. Given the duty hours issues and the continued decrease in reimbursement, such arguments will be given less credence in the future. One could argue that much of student education is self-funded by the faculty from practice income. Certainly, most resident training is funded by the faculty and accrues to most institutions with little financial support to departments. Dr. Wayne Meredith of Wake Forest noted, “the burden of training the next generation of physicians and surgeons rests on the clinical ability of an altruistic group of doctors.”

The current economic climate in many departments is tenuous, and traditional mechanisms of funding both undergraduate and resident medical education in surgery is not likely to be sustainable. Other potential threats loom on the horizon, including restriction on faculty work hours. Academic medical centers need to begin to address funding issues now and prioritize the use of diminishing dollars for education, tertiary clinical care, and research.

Intramural funding mechanisms within departments based on the “eat what you kill” model, while understandable, create potential problems as well. Clearly, some surgeons require an incentive system to drive their productivity. However, the risks of these systems are that ultimately each individual becomes a “cost center” and “unit of production” (to use the words of 1 chair). Such a system will inherently lead to selfishness, loss of collegiality, and the inability to function as a department. An additional problem with systems based totally on RVU-generation is that many of the most valuable aspects of faculty activity produce no RVUs. Teaching students, counseling residents, planning a student or resident research project, mentoring a junior colleague toward membership in the Southern Surgical Association, and helping a young attending with a difficult case have great value but generate no monetary reward. Education is inherently an inefficient process. Enrichment activities never have a RVU attached, but departments must not devalue these activities.

Most of our departments believe we are doing a better job in the past few years because we are working harder at it. Interestingly, almost no one reported a major curriculum change. Instead, a few key people within departments dedicated themselves to better mentoring and increased enrichment activity for students. Most feel we could be doing better and that faculty efforts need to be broadened. However, students’ activities are improved and students appear to be exhibiting interest in our discipline in larger numbers. If true, it indicates to me that personal involvement with students can trump alleged megatrends that might be negative for those considering a career in surgery.

Most departments in the South have large, successful clinical operations. This should give us pause about conventional wisdom, in that many feared academic centers could not survive in the managed care era. It was striking to me that almost every department had nearly every subspecialty program. Unless our primary hospitals are huge, it is often difficult to develop successful programs in areas that require heavy resource utilization. Unless there is excess capacity in our system, each new program or any program growth often occurs at another unit's expense. Many programs might do better to focus on those done well rather than having every program, particularly if there is no educational imperative to have the additional program. The use of affiliated hospitals for training in certain areas has served several departments well in this regard.

There are huge divisions among faculty in many institutions about the role of research in their departments. The issues are complicated, and both sides can make strong arguments. Many medical schools and universities are often faced with a dilemma: to stay focused on student education, resident training, and old-fashioned ways that are often nonglamorous and distinctly unglitzy, or take the steps needed to move ahead with a major commitment to research. It seems that virtually every university in the South now desires to be a “major research university.” Generally, this imperative for major research status has come as an unfunded mandate. For those who do not have a strong research capability in the surgery department, there are often 3 options: produce funded research or be judged a failure or don't even be concerned with research. Surgeons should keep our heads down, our hospitals full and operating rooms busy, and income from these activities can help fund research in other departments.

Clearly, we must continue to advance scientific knowledge, and many departments in our region are leaders in these efforts. Nonetheless, for those departments that do not have a strong research tradition, excellent and collaborative basic science faculty, large endowments, and a good research infrastructure, the costs to jump-start such a research effort are enormous. Many of our departments facing such a mandate appear to me to be woefully unprepared for success.

Does this mean that I am opposed to the growth of both clinical and research programs? Not at all! But, I DO suggest that if departments are to survive in tough economic times, they must prioritize carefully and allocate wisely their increasingly scarce resources—money, faculty, and residents. Hospital administration often wants new programs that are trendy. The current deans’ playbook from the AAMC preaches the necessity of research development. As surgical leaders, we must carefully consider how these efforts can be funded and adapted to the overall goals and objectives of the department.

I have only one suggestion to offer in this regard. One wise chair, Dr. William Wood from Emory University told me when I started this project that I would likely find “a collection of ones with every situation unique and different.” Obviously, that is true to a great extent; yet, I have been more impressed with the commonality of experiences—good and bad—in our surgery departments. The great weakness we have is the lack of a collective voice. We desperately need an effective mechanism to discuss and evaluate common problems with a focused agenda and an action plan formulated (rather than a “woe is me” gripe session). Surely, if the leaders of Southern surgical departments formulated a collective plan about improvement of our VA Hospital relations, someone would listen. I realize this is a federal government bureaucracy, but surly someone would listen! If we could collectively show deans that those departments who shared meaningfully in NIH indirects have a better track record than those who don't, that would likely have more influence than that of a single chair making that assertion. I realize we have a Society of Surgical Chairs, but it does not seem to be an effective organization based on my observations. We have great collective wisdom and experience in this room today—my challenge is for us to organize ourselves, perhaps along regional lines, perhaps using the umbrella of the College into a group of surgeons to address our common issues. While we are doing well in many areas, a few departments are, frankly, in trouble and many are “on the bubble.” We need a voice, and I believe a Southern Surgical Leadership Group could be an effective way to empower departments in novel approaches to our common issues.