SemOpenAlex |

SemOpenAlex

Matches in SemOpenAlex for { <https://semopenalex.org/work/W2027554620> ?p ?o ?g. }

Showing items 1 to 60 of 60 with 100 items per page.

W2027554620 endingPage "967" @default.
W2027554620 startingPage "963" @default.
W2027554620 abstract "It is with profound humility and gratitude that I stand to speak to you today. Humility because there are many of you here who are more deserving of this honor than I, and gratitude because of the honor you have bestowed on me by allowing me to serve as your president this year. Vascular surgery is an unusual line of work. What other job allows you to operate on your fellow man to prevent stroke, avoid amputation, or avert exsanguination from a ruptured aneurysm? It is a privilege to be a vascular surgeon, and I am grateful to have been allowed this undertaking and to my family, friends, colleagues, teachers, and residents who have helped sustain me in this effort. But with this privilege comes a large responsibility. The term doctor derives from the Latin verb docere , to teach, and from the Middle English noun doctour , teacher or learned man. I would like to explore with you some of the aspects of the educational role we fulfill as vascular surgeons. Remember that the tradition in general surgery and, more recently, in vascular surgery has been to voluntarily assume responsibility for our own education beyond formal residency. The major purpose of our society is an annual scientific program. We support research as part of our educational mission so that we augment the information base, rather than only drawing from it. As vascular surgeons, we have been responsible for teaching ourselves new techniques and professional skills and for studying vascular disease and defining outcomes of therapy. I would like to propose that we expand our educational role in both its breadth and depth and assume an increasing advocacy position for our profession and our specialty. At the same time, we must continue in our role as students, expanding our abilities to treat those diseases that we know well with newer and heretofore unfamiliar methods. Full-time clinical faculty represent less than 10% of the physician workforce. This number is not sufficient to maintain an educational undertaking of the breadth and depth I believe we need, nor should this task be assumed by only a small minority of us. That we should have an educational relationship with our patients, to whom we have a direct responsibility, is a given. Second, we have a responsibility to educate the public. The lubricious logic of “managed care” has insinuated itself so subtly into our world that few are aware of its baleful influence on education and research. The public must be made aware of our concerns for the quality of surgical care and understand that these issues are likely to affect it in years to come. Third, we must educate ourselves and our colleagues, if vascular surgery is to continue to remain dynamic and innovative. Part of the difficulty with our current educational role, let alone an expanded one, is that most people do not understand us, nor what we do. You may remember in book XIX of The Odyssey how Odysseus’ disguise is nearly uncovered when his scar is recognized by his nurse Eurykleia, who had treated his thigh wound 20 years earlier. Operating on a person establishes a bond that is more long-standing, deeper, and more personal than other types of professional relationships. For us, this bond is part of the commitment to long-term responsibility and continued care that Dr John Najarian calls the soul of the surgeon.1Najarian JS. Presidential address: the skill, science and soul of the surgeon.Ann Surg. 1989; 210: 257-267Crossref PubMed Scopus (5) Google Scholar It is the intensity and depth of this relationship that most non-surgeons do not fully understand. But operating is not all we do; it is merely a portion of the total care we provide, although laymen and our non-surgical colleagues freely misuse the word “surgery,” when “operation” is more accurate. “The patient was taken to surgery” is not grammatically correct, because surgery is an art and a science, not a time or place. Surgery defines our personae. We share common goals, similar personality types, and work habits; we have all traveled a common path of motivation, hard work, perseverance, and resilience under defeat. We are united in spirit and loyalty to each other, comparable only with the loyalty and camaraderie of men who fight together in battle. When King Henry V addressed his troops before the Battle of Agincourt and said, “We few, we happy few, we band of brothers,” he could have been speaking to us. We are all brothers, and we are our brothers’ keepers. The most significant attribute that is demanded of us is expertise, which is dependent on our initial training and our life-long commitment to education and self-improvement. Expertise is the seminal aspect of our professionalism, and an aspect that allows and obligates us to fulfill the other characteristics that distinguish a profession from a business or trade: the willingness to share our knowledge, even when doing so is against our economic interests; our spirit of public service; the subordination of our self-interest to that of our patients; our acceptance of the belief that our obligations are ascendant over our rights; and our adherence to the concept of internal discipline and peer review. We accept these precepts. The commitment to educational excellence, which we do and should embrace, is not shared by the nation-at-large at any level of education. My local newspapers and yours abound in news that illustrates the insufficiencies of our educational system. At the secondary-school level, enormous effort and expense needs to be diverted away from education and directed toward discipline and personal safety. Only 20% of high school students take physics. Most high school students are poorly prepared in English and foreign languages. Standardized test scores are embarrassingly low. American students uniformly perform poorly, in comparison with students of other nations, in math and science. A local Pittsburgh high school was recently given a monetary reward by the commonwealth of Pennsylvania because its attendance record reached 80%. Could you care for your patients properly if you were absent 1 of 5 days? Would you tolerate this level of absenteeism in your residents, staff, or school-age children? The indifference to academic standards and the low expectations our school systems accept need not be the case. Read The Road From Corain by Jill Ker Conway, the first female president of Smith College, which describes the home schooling of a girl in rural Australia, and see what can be achieved; or read Norms and Nobility by David Hicks, the former rector of St. Paul’s School, to appreciate that students can thrive with an enormously mature and demanding high school curriculum. Conditions are not much more respected in most of America’s universities. Much time is spent in the first 2 years of university attempting to remedy the lack of preparation at the high school level. In too many of our universities, the football coach is more revered and respected than the chairman of the chemistry department, and each is compensated accordingly. Also of concern is what capable people do after they attend university. Although the number of MD graduates per year has more than doubled since 1970 and is probably sufficient for the country’s needs, the number of PhD graduates per year in medicine and biology remains approximately 2000 per year, whereas the number of degrees in business, management, and law, which were each approximately the same as the number of MD graduates in the 1960s, has risen several fold.2Healy B. Innovators for the 21st century: will we face a crisis in biomedical-research brainpower?.N Engl J Med. 1988; 319: 1058-1064Crossref PubMed Scopus (55) Google Scholar Japan trains 10 engineers for every lawyer; our nation’s ratio is the reverse.3Lamm RD. The uncompetitive society.Dartmouth Alumni Magazine. 1987 May; : 32-38Google Scholar The future of our society is dependent on technological vigor and scientific creativity, rather than the ability to produce more litigation. It is crucial to that future that a healthy portion of the best and the brightest students enter science and medicine. Turning to the professional level, I am always disappointed to realize that some people don’t love and respect what they do enough to accept an element of self-sacrifice. A couple of years ago, an attorney wrote a Wall Street Journal editorial describing, somewhat gleefully, how he had successfully led a referendum to thwart his bar’s proposed mandatory 12-hour-per-year Continuing Medical Education (CME) requirement, pointing out that 86% of its members voted against a comprehensive program and 78% of its members voted against an ethics-only program.4Chretien PN. The bar’s back-to-school scam. Wall Street Journal.in: 1996 Jan: 17Google Scholar CME requirements are one thing about which I’ve not heard vascular surgeons complain, although we seem willing to complain about everything else. Twelve hours a year—1 hour a month—seems more of an inconvenience than a sacrifice, and it is hard to respect the mettle of a professional who cannot accept this with equanimity. Most states require physicians spend 50 hours per year for CME requirements, and most of us voluntarily submit to periodic board recertification as well. I remember reading how Will and Charlie Mayo traveled weekly by train from Rochester, Minnesota, to Chicago to attend Saturday grand rounds—easily 12 hours per trip. Justice Thurgood Marshall’s mother pawned her wedding and engagement rings, which she was never able to reclaim, to provide for her son’s college education. We should be proud of the firm commitment to self-education made by vascular surgeons. You may recall that the report authored by Dr James DeWeese, a past president of this society, titled “Optimal Resources for Vascular Surgery,” made recommendations concerning the training of vascular surgeons,5DeWeese JA Blaisdell FW Foster JH. Optimal resources for vascular surgery.Arch Surg. 1972; 105: 948-961Crossref PubMed Scopus (42) Google Scholar which ultimately led to criteria for vascular fellowship training. As a community, we have helped establish the vascular surgery examination and sat for it and for its recertification examination. We have worked together to create vascular fellowships and train residents and fellows. Almost entirely within our specialty, we have worked at perfecting and teaching each other endovascular techniques. I am amazed at the ignorance and lack of realism about surgery exhibited by highly educated and sophisticated persons. A recent New York Times editorial by J. Phillip Lathrop, a vice president of the major management consulting firm Booz-Allen and Hamilton, produced recommendations about hospital care, including double-sized hospital beds, 21-inch television sets with cable, the ability to “lock out” doctors and nurses who visit patients at inconvenient times, refreshment centers with access from the beds, and a voice-mail system to screen calls.6Lathrop JP. No pain, no gain? Forget it, doc.New York Times. 1998 Feb 1;Sect; 3: 9Google Scholar At first, I thought the article was a satire on criticism of health care, but was disabused of this notion after reading the author’s book, Restructuring Health Care: The Patient-focused Paradigm . My typical patient is approximately 75 years old, takes more than 10 medications daily, is likely to have difficulties with hearing or mobility, has a 70% chance of having diabetes mellitus, and a 50% chance of having had cardiac intervention before being referred to my care. If this is the level of understanding of a sophisticated professional who serves as a health care consultant, how can we expect the average patient to exercise informed judgment on substantive issues, such as the need to operate on an asymptomatic 90% carotid stenosis, the importance of cardiac evaluation in a patient with diabetes mellitus who has silent angina or mild claudication, or the misconception that anything not involving an operation is ipso facto better than something that does? We need to do better in explaining to the public that the cost of health care is not equivalent to its value. Despite our clinical expertise and good intentions, we have been unable to slow the ineluctable expansion of what I call the medical administrative complex. Ten years ago, Woolhandler’s study found that health care administration in the United States accounted for 19% to 24% of the health care budget; this number is still rising.7Woolhandler S Himmelstein DU. The deteriorating administrative efficiency of the US health care system.N Engl J Med. 1991; 324: 1253-1258Crossref PubMed Scopus (236) Google Scholar With each rise in administrative costs, the percentage of the health care dollar actually expended on health care falls. The insurance companies call the percentage of their premium revenues spent on health care the “loss ratio.” I have always found this term objectionable, because it has a pejorative connotation, which it should not. The money insurance companies spend on health care is not a loss, that is what they are expected to do. The Pennsylvania Insurance Department reported that in 1991 our health maintenance organizations expended 87% of their revenue on medical care, whereas in 1994 this figure declined to 74%. The remainder, 13% in 1991 and 26% in 1994, went to administration, extraordinary items, and profit. A good portion of this sum, which we saw double in 3 years, was devoted to advertising, marketing, and auditing of physicians. I believe that insurance companies and health maintenance organizations should use their premium revenues on health care, with an appropriate dividend for stockholders and administrative expenses. A higher percentage of actual insurance premiums spent on health care is a gain, not a loss. Furthermore, after third-party payers dilute the health care dollar with their administrative costs, additional funds are siphoned away from health care by hospital and nursing home administration, and the physicians’ remuneration is ultimately diluted by their overhead expense of approximately 45%, much of which is used to support an increasing administrative load and the cost of liability insurance. This administrative load is not a feature of health care systems in Canada or other western countries, and the only exception to it in the United States is the Shriners’ Burn Hospitals. Manpower deployment is another way of looking at costs. Between 1968 and 1993, the portion of US medical care employment devoted to administration grew from 18% to 27%. These figures are understated, because they do not include the quarter of a million persons who work for health insurance companies, nor those who work for corporate health benefits departments. During this time, the number of physicians grew 77%, the number of registered nurses grew 163%, and the number of health care administrators grew 691%. At present, there are 1.8 physicians and nurses for every administrator.8Himmelstein DU Lewontin JP Woolhandler S. Who administers? Who cares? Medical administrative and clinical employment in the United States and Canada.Am J Public Health. 1996; 86: 172-178Crossref PubMed Scopus (43) Google Scholar Think of what this means: When you operate on a patient with a ruptured aneurysm, your surgical and anesthesia team, operating room nurses, and intensive care unit nurses—a minimum of eight people—are theoretically supported by 4.4 administrators. I keep looking over my shoulder in the operating room and intensive care unit between dusk and dawn, and I have yet to see one administrator. Perhaps you have. Why has this happened? The administrative hierarchy, and in this I include the government, has created a self-perpetuating skein of forms, check lists, consents, and attestations, which then require a host of new persons for their execution. Medical records is such a growth industry that performing an outpatient varicose vein excision in my hospital fills the patient’s chart with at least 17 different forms. We need to be more effective and visible on hospital committees, boards, specialty societies, and with the Joint Commission for Accreditation of Health Care Organizations. We need to inform our patients individually and the public collectively about what is happening and what its significance and cost are. When we do, there is appropriate societal outrage. During the last 25 years, vascular surgery has made enormous advances in technologic progress and patient safety. Our mortality rate for elective aortic surgery is 2% to 3%, when 25 years ago it was 10% to 15%; our perioperative stroke rate for carotid endarterectomy is approximately 2%, a figure that 25 years ago was achieved by only a few masters, but is now routine for well-trained vascular surgeons. The techniques of small anastomoses are exploited for distal bypass grafting and hemodialysis access. Experienced vascular surgeons, particularly those who hold the certificate of added qualifications in vascular surgery, have better outcomes for major arterial procedures.9Pearce WH Parker MA Feinglass J Ujiki M Manhein LM. The importance of surgeon volume and training in outcomes for vascular surgical procedures.J Vasc Surg. 1999; 29: 768-778Abstract Full Text Full Text PDF PubMed Scopus (246) Google Scholar Our diagnostic studies are more accurate and safer. We operate on older and sicker patients each year. Has health care administration produced similar advances? It seems that each procedure, each diagnostic test, and each piece of terrain are laboriously inspected for cost-effectiveness, safety, and lack of personal self-interest, except that which is under the administrator’s feet.7Woolhandler S Himmelstein DU. The deteriorating administrative efficiency of the US health care system.N Engl J Med. 1991; 324: 1253-1258Crossref PubMed Scopus (236) Google Scholar Juvenal wrote, “Sed quid custodet ipsos custodes?” Who guards the guardians? Perhaps we should insist that performance standards be applied to third-party payers and that each new bureaucratic requirement be examined for necessity, each additional administrator justify his cost-effectiveness. We must educate the community, particularly the business community, that sometimes bigger may be more profitable, but not always better. The business community has been guilty of willingness to accept health insurance that offers a modest discount in total cost, but with a substantial diminution in actual health care provided. Insurance company buy-outs and hospital mergers and acquisitions take on the flavor of professional sports franchises, rather than health care institutions. “Competitive edge” and “economies of scale” are clichés that are invoked to promote these mergers, yet some unions are short-lived, and many mergers cause professional disruption, with loss of experienced medical and technological personnel and consequent diminution in the quality of patient care. In Pittsburgh, Allegheny General Hospital, an institution with a century-old tradition and enormous expertise in trauma and cardiac surgery, had a chief executive officer who convinced his board and medical staff of the need to affiliate with a medical school, ostensibly as a way to legitimize non-university training programs. The execution of this seemingly professional goal resulted in the purchase of one Philadelphia medical school and the assimilation of a second and then a buying frenzy to acquire several hundred primary care practices and several hospitals, to form Allegheny University and the Allegheny Hospital Education and Research Foundation (AHERF). Along with these hospital purchases came the hospitals’ debt, and along with the purchase of primary care practices came the eventual realization that patients simply did not care to travel across a large city to be hospitalized. Before this institution finally filed for bankruptcy last year, AHERF encompassed 55 corporate entities and 10 separate boards, some of which held meetings in Europe, 132 directors, and 117 senior managers, 77 of whom earned more than $200,000 per year. AHERF also owned private jets, a skybox at Veterans’ Stadium, and an insurance company in the Cayman Islands.10Pittsburgh Post-Gazette. 1998 Sep 17; (Sect. C): 1-4Google Scholar One result of this financial disarray has been the departure of surgical residents and of recruited faculty, to the detriment of patient care and surgical training. Other Philadelphia medical schools have suffered as well, as they scrambled to compete, then saw their debt climb and their bond ratings fall. As you might guess, physician input in this endeavor was minimal. We must educate our patients and serve as their physicians, as well as their surgeons. There is no medical subspecialist counterpart to vascular surgery, as there is for gastrointestinal surgery, neurosurgery, or cardiac surgery, and we must step into this breech. Of course, patients need to be counseled about tobacco avoidance, weight loss, attentiveness to diabetic foot care, and the chronicity of venous stasis disease. But more of our time needs to be directed toward correcting the erroneous information patients have received. The media seems to abhor peer review journals in favor of anecdotal data and unsubstantiated claims. Laser reconstruction of obstructed arteries was widely publicized a few years ago and has been largely forgotten. Minimally invasive coronary bypass grafting was loudly proclaimed; it, too, has been abandoned by many surgeons who tried it. Unrealistic and inappropriate media claims must be challenged by vascular surgeons through effective and non-confrontational communication.11Ernst CB. Presidential address: Society and vascular surgery—The need for humanism and research.J Vasc Surg. 1992; 14: 267-274Abstract Full Text Full Text PDF Scopus (3) Google Scholar Wound care centers are a growth industry, yet many omit the expertise of vascular surgeons who address venous and diabetic ulcers with experience and common sense. This audience knows that the cost of a nurse seeing a patient at home is far in excess of a vascular surgeon following up on the patient in his office. Managed care would impede continuity of care by convincing patients that long-term follow-up after arterial surgery should be the province of a primary care physician, who can be bludgeoned, particularly under capitation, into omitting necessary studies in the interest of cost. We must be attentive to the educational needs of our students and our trainees and to our nurses and emergency room staffs. The consistent 20% failure rate on the American Board of Surgery and vascular surgery examinations suggests that those of us who teach are not doing so with maximum effectiveness. Five years ago, a study from the University of Kentucky compared the ability to perform a vascular examination and evaluate its findings among groups of medical students and interns. These skills are crucial, because decision-making in vascular surgery is contingent on the ability to obtain an accurate history and perform an appropriate physical examination. Overall, correct scores were 43% at the M3 level, 39% at the PGY1 level, and a modest improvement of 62% at PGY2 level. Interestingly, medical students who had a significant exposure to vascular surgery, either with a vascular surgery rotation or a faculty preceptor who was a vascular surgeon, had scores that were nearly double those of their peers. This study suggests that close exposure to a vascular surgeon is more effective in the development of adequate skills than mere exposure to lectures, rounds, and conferences. 12Endean ED Sloan DA Veldenz HC et al.Performance of the vascular physical examination by residents and medical students.J Vasc Surg. 1994; 19: 149-156Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Finally, within the medical community there is work to be done. The understanding of the evaluation and treatment of deep venous thrombosis and superficial phlebitis is not ideal. There is still widespread nihilism regarding the benefits of carotid endarterectomy and ignorance of the excellent results achieved by experienced vascular surgeons. There is abuse of the noninvasive vascular laboratory, at which multiple tests are ordered when only one test is indicated. There is reluctance to use the vascular laboratory for long-term follow-up of patients after infrainguinal reconstruction or of patients with carotid stenosis. We are asked to operate on patients with ruptured aneurysms who have been told that they were too high risk for elective surgery. We could be more effective advocates of stroke prevention if we were allowed to follow-up on patients in the way we know how. We have done much, but we can do more, if we are willing to see our educational role in a broader sense and give of our time and energy. We must not go gentle into that good night. The negative impact of administrative proliferation is obvious to all of us. Merger mania may be profitable to the business community, but unless it improves health care, we should speak out against it. We must continue to find the time and energy to devote to our own education and to our hospital personnel, students, and trainees. We should not fall into what Proust called “L’influence anesthesiante de l’habitude ”—the anesthetizing influence of habit—but rather redirect our efforts toward common goals. If we work together, we can make a difference. We cannot curse the darkness if we are unwilling to light a candle. Thorton Wilder wrote, “We come from a world where we have known incredible standards of excellence, and we dimly remember beauties which we have not seized again.” We are all brothers, and we are our brothers’ keepers." @default.
W2027554620 created "2016-06-24" @default.
W2027554620 creator A5012506485 @default.
W2027554620 date "1999-12-01" @default.
W2027554620 modified "2023-10-16" @default.
W2027554620 title "Presidential address: Education and brotherhood" @default.
W2027554620 cites W1972670445 @default.
W2027554620 cites W2024734348 @default.
W2027554620 cites W2034700465 @default.
W2027554620 cites W2066585925 @default.
W2027554620 cites W2074453801 @default.
W2027554620 cites W2085016433 @default.
W2027554620 cites W2094127986 @default.
W2027554620 cites W2331101518 @default.
W2027554620 cites W2400297929 @default.
W2027554620 doi "https://doi.org/10.1016/s0741-5214(99)70033-9" @default.
W2027554620 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/10587379" @default.
W2027554620 hasPublicationYear "1999" @default.
W2027554620 type Work @default.
W2027554620 sameAs 2027554620 @default.
W2027554620 citedByCount "0" @default.
W2027554620 crossrefType "journal-article" @default.
W2027554620 hasAuthorship W2027554620A5012506485 @default.
W2027554620 hasBestOaLocation W20275546201 @default.
W2027554620 hasConcept C17744445 @default.
W2027554620 hasConcept C197487636 @default.
W2027554620 hasConcept C199539241 @default.
W2027554620 hasConcept C2992498528 @default.
W2027554620 hasConcept C3116431 @default.
W2027554620 hasConcept C71924100 @default.
W2027554620 hasConcept C94625758 @default.
W2027554620 hasConceptScore W2027554620C17744445 @default.
W2027554620 hasConceptScore W2027554620C197487636 @default.
W2027554620 hasConceptScore W2027554620C199539241 @default.
W2027554620 hasConceptScore W2027554620C2992498528 @default.
W2027554620 hasConceptScore W2027554620C3116431 @default.
W2027554620 hasConceptScore W2027554620C71924100 @default.
W2027554620 hasConceptScore W2027554620C94625758 @default.
W2027554620 hasIssue "6" @default.
W2027554620 hasLocation W20275546201 @default.
W2027554620 hasLocation W20275546202 @default.
W2027554620 hasOpenAccess W2027554620 @default.
W2027554620 hasPrimaryLocation W20275546201 @default.
W2027554620 hasRelatedWork W1859678881 @default.
W2027554620 hasRelatedWork W2100418895 @default.
W2027554620 hasRelatedWork W2245464081 @default.
W2027554620 hasRelatedWork W2299530584 @default.
W2027554620 hasRelatedWork W2324667720 @default.
W2027554620 hasRelatedWork W2417758362 @default.
W2027554620 hasRelatedWork W2504724958 @default.
W2027554620 hasRelatedWork W2590195183 @default.
W2027554620 hasRelatedWork W4231917633 @default.
W2027554620 hasRelatedWork W4247666012 @default.
W2027554620 hasVolume "30" @default.
W2027554620 isParatext "false" @default.
W2027554620 isRetracted "false" @default.
W2027554620 magId "2027554620" @default.
W2027554620 workType "article" @default.