GYNECOLOGY AND

~ THIRTY-THREE years ago a group in the past eight years, of the length and char- lI) of very wise men founded the Amer~ acter of the training required. Others felt, ~ ican College of Surgeons. It was however, that all those who proposed to spe- : their hope that by gathering to- cialize should be forced at an early stage in &: gether in such a College all the surgeons and their graduate training to demonstrate to a t..D surgical specialists who were known to be court of examiners that they were proficient in ~ morally and ethically fit and who had demon- the principles of surgery and in the allied basic ~ strated by their training and by their standing medical sciences. From this arose the Ameri- j in the professional world that they were prop- can Board of Surgery and the boards of the ~ erly qualified, the standard of surgical care various surgical specialties, to which the Col- might be raised to the level that a great people lege elects representatives. ':£ deserves. It was hoped, too, that with the The aim of both the College and the Boards r-4 lapse of a few years the diploma of Fello"wship has been the improving of the quality of in the College would become so desirable and American surgery and both have been success- so necessary that all who proposed to practice ful. The College insisted on minimum periods surgery would seek it and that by and by it of apprenticeship, evidence of high moral and would constitute a clear index whereby those ethical standing, and proof that the candidate who were qualified to do surgery could be dis- had shown ability in practice. It concerned it- tinguished from those \\·ho were not. self with the raising of the standards of the 1 Since the day of its foundation the College hospitals in which its Fellows would study and / has grown and prospered and it has done those work, it busied itself with advanced surgical !( things to a superlative degree for which its education, as indicated by this Congress today '- founders so fondly hoped. and it is now engaged in what may prove to be As time went on, hO\\'ever, and the future of its greatest effort on behalf of American sur- the College had been firmly established, there gery, the establishment of adequate graduate arose both within it and without, a demand for training. The Boards have outlined more a definite raising of the requirements for ad- sharply the periods of hospital training that mission to Fellowship, both in the form of are required and have made sure, by requiring longer and better practical training and of the candidates to pass searching examinations, proficiency not only in surgery but also in all that they have an adequate knowledge not "lJ.ebasic sciences related to it. The College only of the art of surgery but of the basic ~cognized this demand by two modifications, sciences, without which no man can be a true surgeon. Address of the retiring President, before the Clinical Congress otthe American College of Surgeons, Cleveland. Ohio, December Speaking now, not as President of the Col- IHo, 1946. lege, but as a Canadian and a most friendly 513 onlooker, I recognize the same high motive in one might suppose. While most hospitals are both the College and the Boards, and I see interested to a certain extent, because certifi- great virtue in what each has done. It seems cation by the College that a hospital is ap- to me, however, that it is a pity to have two proved for graduate training would ensure a separate roads to public recognition and that a constant supply of good internes, yet many of combination of the two, with adoption of what these hospitals balk at the radical staff reor- is best in each, would add great strength to the ganization involved and hesitate to put the crusade for higher standards and would ulti- time and effort into a teaching program thr • mately serve the people best. could be considered adequate. It is clear thaL But while the setting up of standards for to make a success of its graduate training plan qualification to practice surgery is a step in the College will require the good will of the the right direction it will prove quite futile if public and the whole medical profession and . conditions are such that these standards can- the strong support of all the Fellows. be achieved. What does it profit to tell a In support of the program of graduate oung graduate that he must serve a period of training I propose to discuss with you briefly / I~supervised training in an approved hospital, the plan which has .been in operation in the V f extending over a period of 3 or 4 years, if a University of Toronto for the past 18 years. I ( sufficient number of such hospitals do not have no thought that it is adaptable to all situ- \ exist? A survey of the hospitals of Canada has ations nor have I any notion that it is as good as shown that only a few can at present be ap- that in many of the great American universities, proved for graduate training and the same particularly those with sufficient endowments lamentable state of affairs obtains in the to enable them to grant numerous fellowships United States as well. Only in a few of the toward graduate training. It does illustrate, hospitals attached to medical schools is there however, what can be done by long term any attempt at the planned training of in- planning and by persistent effort at reform. ternes and residents and in very few of these, Twenty-five years ago the Toronto General any provision for instruction in the basic sci- Hospital (1,000 beds), staffed by the best sur- ences. How man'y hospitals do you know geons in the land, all members of the Medical where a three year assistant is of- Faculty, had never trained a surgeon. In- fered, or where regular ward rounds or con- ternes came for a year or two and departed, ferences are held, or where supervised courses usually into general practice. Those who of· study are provided in anatomy, applied aspired to become surgeons sometimes went to physiology, and applied pathological chemis- New York to see~ a further interneship, or try? And how many hospitals do you know more often, went to London or Edinburgh to where internes are encouraged to make use of study for the coveted diploma of Fellowship in the libraries or to take part ip surgical re- one of the Royal Colleges. These Fellowships search? The answer is, yery few. There are, of were won by passing the stiffest kind of ex- course, outstanding examples to the contrary, aminations in anatomy, physiology, where the training of the interne is a major and surgery and they were a guarantee that interest of the stafi but when one adds up the the successful candidate at at least one stage in number of these hospitals and makes up the his career had been familiar with what the grand total of the graduates receiving such textbooks said about them. They did not, training it will be found that the number is however, guarantee that the Fellow had any very small. satisfactory apprenticeship or had become a This is the reason for the present activity of master of his craft. It was only when he re- the College in graduate training and for its turned to his home and had received a junior effort to induce hospitals to make the neces- hospital appointment that his practical trair - sary reorganization of their staffs and to adopt ing began. ' the resident system. Under this system a small group of surgeons Unfortunately the reformation that the Col- was developed from which the lege has in mind is by no means so simple as and the hospitals selected their staffs. Then came the era of the building of small versity staff appointments here or elsewhere hospitals and with it the enormous increase are sele£ted to remain as Fellows in general in the number of surgical operations. These surgery or in one of the surgical specialties. operations, of necessity, were performed by During, this period they rank as junior mem- practitioners of very little training who had bers om the staff and are permitted to as- learned what they knew from books, from ob- sume DDl:dependentresponsibilities. servational tours, and from the hard experi- ThiS plan of graduate training is quite elas- "'nce of trial and error. I know one such hos- tic. _-\5 I have outlined it, it is a minimal pital serving a neighborhood of six or seven course which may not be shortened but which thousand people where the operating rooms may k lengthened as circumstances seem to are busy every day from nine to one and wpere require. Thus for the young man whose ob- not a single operator ever had more than a ject it tS to leave the university and go into rotating interneship. It "vas to try to force an pradlll«:ltat a distance, we suggest that he take elevation of the standards of education of in ~t!ion to his general surgical training, as these surgeons that the American College of many (!)f the surgical specialties as possible. Surgeons was founded. Six mnxruthsassistan t residencies in orthopedic Recognizing that the raising of standards su~, gynecology, , and the surgery was useless unless provision were made for ofdrillrdJl'lOodare of great value to him. On the training candidates to meet those standards other mnd for the man who has made up his the University of Toronto, 18 years ago, em- mind 100 devote himself to one of the special- barked on a program of graduate surgical ties, 5ilD€has , we release education which gradually became standard- himfwffi service in gynecology and urology ized and which now constitutes the chief and furmithim to 6 months in and source of supply of trained surgeons for the an e:xil.J11a8 months' fellowship in orthopedics. Province of Ontario and indeed for the whole FfYIr men who because of their scholastic at- country. tainnments, general aptitude, and qualities of The course is based on the theory that if the mind are considered as possible candidates, at highest type of medical graduate is attracted some f.uture date, for residencies and ulti- to it, the best results will be obtained by com- mateily for staff appointments, a longer course bining the virtues of the apprenticeship sys- is pTDlvided. These men, after their rotating tem with those of the tutorial system. We had inter.D!tship, spend one or more years)n the in mind that to ensure that the student profit Departtments of Anatomy, Physiology, Patho- most from his years of surgical residency he logica!!Chemistry or Pathology before finally must be forced to undertake systematic study. embrurll:ingon their surgical training. Then, if To do this we arranged a definite curriculum as aS5futant residents they have continued to composed both of practical training in hos- do wdil, they are sent abroad for a year in pital and of the instruction and study neces- some active surgical center before returning sary to enable the candidate to face examina- for their period of residency and ultimate ap- tion for the :Master's degree. 1I.S. pointment to a Fellowship in Surgery and a The following is the minimum course: junior post on the staff. Often before finally 1. A rotating interneship in an approved settlin;g;down to their staff appointment these hospital with at least 6 months of general men Ep:enda year in one of the more active . producing surgical laboratories, a preparation 2. At least 6 months in pathology. for research work when they come home. 3. One year on a general surgical ward. As <2lready mentioned this planned appren- 4. Six months in each of three surgical spe- ticeshi[p is combined ,,,ith a prescribed cur- ~ialties. ricultllln of studies leading to the degree of ~t the end of this minimum course many of mas1:f!l of surgery. To win this degree the the candidates qualify for the ~I.S. and go out candidate must pass a stiff examination in to practice. Others who have shown outstand- surgnl anatomy and in applied physiology ing qualities and are thought worthy of Uni- and pathological chemistry. Later he faces written and clinical examinations in pathology internes and assistant residents as servants and surgery. Finally he must present a thesis must be abandoned if we are to get good re- on some clinical or experimental studies con- sults. Indeed, I am convinced that even in ducted by himself during his years of training. many old established teaching hospitals a re- To encourage these young men to take full birth in the ideals and aspirations of the staff advantage of their opportunities the Univer- will be required before real progress is made. I sity has given them the privileges of the ana- suggest to you that the ideal of the teaching .tomicallaboratory and has provided first class surgeon should be not how skilful and impres- ) tutors. Half of the assistant residents go to sive he can make himself by constant practice. the laboratory on one night a week, and the and repetition, but how many young men he other half on another. In this way they re- can train to be as good or better than himself. view the whole human anatomy in two years. Only when such an ideal is established can we Similarly the Department of Physiology hope to supply the needs of our country. conducts a series of lectures and discussion The difficulty is that busy surgeons often groups on applied physiology and the Depart- find it irksome to stand on the opposite side of ment of Pathology does like\yise. the table assisting a young tyro in his first And finally, in order that these young men difficult operations. Too often they impa- may be prepared for the examination for Fel- tiently do the operation themselves or turn the lowship in one of the Colleges or for certifica- job over completely and take no further re- tion as specialists by one of Canadian or Amer- sponsibility for it. This, in my opinion, is poor ican Boards, a series of evening discussion teaching and is clear evidence that it is time groups are directed by younger members of for a change in the personnel of the staff. the staff on the principles of thoracic surgery, There is, of course, no excuse whatever for the , neurosurgery, urology and old custom in \\"hich a star performer at some orthopedic surgery, which many of the as- well known metropolitan hospital posts a list sistant residents may have missed in their se- of operations for certain days in the week and lection of specialties. does them all himself. Fortunately that sort Such a program may appear pretty exten- of thing has almost passed away. sive and to require a great deal of organiza- The truth is that in modern first class teach- tion. This is not so, however, for the various ing hospitals the diagnosis should be made, the departments invoh-ed have shown keen in- type of treatment selected and the operation terest in graduate education and are glad to performed by the resident staff under the con- have students \yho are in earnest in their stant guidance and supervision of their teach- search for knowledge. The Department of ers. The attending staff should reserve for it- Anatomy afiords a good example. In these self only special groups of cases on which they days when the time allotted to the teaching of are conducting clinical research and those anatomy to undergraduates is being so re- cases which obviously require more experience duced that none but a superman could be ex- and skill than the assistant residents have so pected to acquire any practical knowledge of far acquired. These are the hospitals with it, the department \wlcomes the opportunity huge lists of applicants and which attract the to teach students \yho have the time to devote high honor graduates from near and far. Such to it and who really want to know what is hospitals are famous across the land for the under the skin. quality of the men they produce. The real difficulty in inaugurating such a But, as I have already pointed out, Heel planned course of graduate training will be that there should be added to this program a met with in the Department of Surgery itself. planned purposeful course of study, leading The idea that as members of the surgical staffs to an examination for a higher degree and to of teaching hospitals our most important duty FellO\\"ship in our Colleges. Such a curriculum. _ is to train surgeons has not been appreciated spread over 3 or 4 years, is no hardship to the by many and is an idea which requires propa- student and I feel sure that a review of the ganda to inculcate. The old plan of using basic sciences carried out concurrently with clinical work, and a definite program of clinical problem is simple but if it is at a distance it is study and instruction results in a far sounder more difficult. It can be overcome, however, surgical education than the haphazard meth- as has been done in Hamilton, Ontario, where ods of other days. the assistan t residen ts come 40 miles by train But even with all the teaching hospitals of to spend one evening a week in the anatomical America supporting such a plan, not nearly laboratory and to attend a lecture on applied enough opportunities for graduate training physiology. will be provided. To giYe such opportunities Now while I am urging that it is the plain .0 the crowds of young men now demobilized duty of all surgeons on the staffs of puhlic hos- from the Armed Forces and to meet the urgent pitals and particularly the Fello\ys of this Col- needs of the country, other means must be lege, to join in this campaign, I should point found to secure for these men the 3 or 4 years out that the reward for hearty co-operation in of dinical training necessary and to give them it will be great and the penalty for failure will an opportunity to review the basic sciences. also be great. You must all haye observed This is the basis of the present "Graduate that with the establishment of higher stand- Training" campaign of the College. It is ards for qualification by the Boards and the really an effort to persuade the larger non- College, those hospitals known to provide ap- teaching hospitals to adopt the "resident" proved courses of training are being so inun- system and certain minimum standards con- dated with applications that they are able to sidered by the College and the Boards as es- fill their resident staffs with the pick of the sential to the proper training of a surgeon or graduating years. On the other hand those surgical specialist. hospitals which have not b~en approved for If this campaign is successful it will un- graduate training or are known to provide in- doubtedly overcome the present dearth of different courses, have very few applications qualified surgeons. It can be successful, how- and these only from graduates who are not ever, o:lly if it has the overwhelming support acceptable ebewhere. The result is too ob- of the Fellows and it is for this that I appeal vious to require comment. tonight. As the years haye rolled along it has been To make it work the hospital must have a interesting to observe the results of our plan- sufficient number of public ward beds to pro- ned course of training. Some of the gradu- vide an adequate service for a resident staff. ates who have shown aptitude for teaching or The attending staff must be persuaded that in research have won appointments on teaching return for privileges of their appointment it hospitals and a few have become professors. is their duty to train the internes. The staff The outstanding result, hmyever, was that should be small and should contain one or when the Canadian .-\rmed Forces needed more men who have been trained in the "resi- highly qualified young surgeons they were dent" system in a teaching hospital. They ready and were able to give our soldiers, must be prepared to give much time to a sailors, and airmen a service that has hitherto teaching program, much as is done in teaching been unsurpassed. And nmv \vith demobiliza- hospitals, and to compensate younger mem- tion these officers are settling into ciYilian life bers of the staff an honorarium of some sort and bringing to the Canadian people both in should be provided. the cities and towns a quality of service of In order that an assistant residency in these which their teachers are very proud. hospitals may qualify a candidate for admis- This group which now has grown to seventy- sion to examination by one of the Boards or five, has banded itseif into a club which meets for Fellowship in the College, provision must once a year to spend a day at the hospital be made for instruction in the basic sciences. where they were trained ancI to enjoy a clini- "his calls for an arrangement with a neighbor- cal program and a dinner. To this gathering ing medical school and may require a moder- are brought all the trials and difficulties of ate expenditure to defray the e:-.."pensesof the practice and it is seldom that the trouble is so school. If the hospital is in the same town the great that it cannot be solved. Through it there has developed an excellent esprit de court of examiners skill in the art and science corps and a tradition which ensures that the of surgery, gives a stimulus to the whole general plan will long continue. course. Gradually the tradition develops that It is the opinion of this group that the the M.S. is more than a diploma won by ex- young surgeon, recently certificated and ac- amination but that it is a written guarantee cepted to Fellowship in one of the colleges that the holder is known to his teachers to be . should limit himself entirely to surgery or his thoroughly qualified to practice his profession. particular specialty. At first it was thought Because of this fact the attainment of the that this could not be done and that a surgical degree is much desired. practice could only be acquired through gen- I have taken long to tell you the story of our eral work. It has been shown beyond a doubt, efforts in Toronto. As I said earlier, I have no however, that this is wrong and that, on the notion that our plan is an ideal one or that contrary, it is the surest and quickest road to better plans do not exist. At this time, how- success. The explanation is that general prac- ever, when the College is engaged in a great titioners are far more willing to refer surgical campaign to provide an increased supply of work to a specialist who is not in competition qualified surgeons it may be helpful to those with them for general practice, than to an- who will be engaged in organizing and ad- other . They do it, too, ministering somewhat similar plans, to hear of without asking a share of the fee, which is the difficulties and disappointments and the something on which to ponder. triumphs of a plan that has been in operation In thinking over our experience of the past for 18 years. 18 years in this planned course of graduate The honor of being President of this great training, I commend to your consideration the College throughout the whole of the European following suggestions: and Asiatic war has been far beyond my des- First. In order that the student may ac- serts. The last Clinical Congress took place quire a satisfactory knowledge of anatomy, in Boston just before Pearl Harbor and you applied physiology, and applied physiological elected me to the presidency in order that you chemistry he should be provided with a plan- might do honor to my country which was al- ned curriculum of studies running concur- ready deeply involved in war. Thank God, as rently with his apprenticeship. allies, we came through safely together and Second. In order that he may be stimu- can now turn our minds to the urgent prob- lated to engage in these studies earnestly and lems of peace. Of these none is more impor- not perfunctorily he should be confronted tant than the health of the people, and, as far with written and oral examinations. as this College is concerned, than that each Third. The awarding of a degree such as one of our citizens, be he in the heart of the "Master of Surgery" to candidates ,Yho have city of New York or on the fringes of Arctic shown a practical knowledge of the basic med- civilization, may be assured, in some way or ical sciences and who have demonstrated to a another, of competent surgical care.