Costs of Training Ethical Considerations of Certification

Following initial reports of laparoscopic cholecystectomy, surgical practice in the United States has undergone substantial change. There has been a torrential outpouring of interest to learn new endoscopic techniques. The costs absorbed by practitioners to attend courses were hefty and few academic centers availed themselves of the early training experience (156). Some groups started small businesses of training surgeons, as the demand was so acute and the courses themselves proved financially rewarding. This scenario is not entirely different to the training conditions of the late 1800s in the United States, where Halsted (157) stated, "the man who had settled his tuition bill was thus practically assured of his degree, whether he had regularly attended lectures or not."

The history of postgraduate surgical education is very limited. The laparoscopic boom of the early 1990s changed all of this. Traditional academic centers were bypassed by industry and practicing surgeons began courses "for profit" in unregulated fashion, with no defined objectives, and with no consideration of surgical application of skilled technique. Dr. Seymour Schwartz (158) stated at one point, "the speed of change has resulted in a scenario where the more senior educators, usually those responsible for the structure and format of educational programs, are the least informed about modern elements." The patient was the ultimate denominator in this process of an unregulated sprint for application of complex technology to a common clinical condition. Since organized, academic medicine was unwilling or unable to halt this process, the State of New York issued a memorandum in 1992 that training and credentialing surgeons needs further scrutiny (159). As of 1999, according to the American Board of Surgery, the mean number of advanced laparoscopic procedures performed by graduate trainees was fewer than 10 (160). The American Board of Urology has not issued any information regarding graduate training patterns for U.S.-trained urologists, but surveys among endourologists at leading academic centers suggests that no letters of credential support has yet been issued for laparoscopic urologic surgery.

Interestingly, the Society of American Gastrointestinal Endoscopic Surgeons (161) approved guidelines for granting privileges to general surgeons performing laparoscopy in May of 1990. Individual institutions are currently encouraged to develop their own guidelines on accreditation. The Society of American Gastrointestinal Endoscopic Surgeons board of governors developed and issued the "framework of postresidency training" in 1994, to serve as a template for the American Medical Association's guidelines for postresidency training and credentialing. In 1997, in cooperation with both U.S. Surgical Corp. and Ethicon Endo-Surgery, Society of American Gastrointestinal Endoscopic Surgeons commenced biannual courses in advanced laparoscopic surgery. By 1998, Society of American Gastrointestinal Endoscopic Surgeons published its first manual on laparoscopic surgery and began work on an interactive computer-based program to enhance surgical laparoscopic skill, called the fundamentals of laparoscopic surgery program (161). No other organized group, other than the Society of Laparoscopic Gynecologists has been more proactive in the educational concerns that continue to haunt advanced laparoscopic technology and their clinical application. Frank Spencer's (162) presidential address of the International Cardiovascular Society 25 years ago is a poignant today as it was then, "Clearly a large part of education, especially in this age of rapid obsolescence of knowledge within a few years, should be in the postresidency years. This seems particularly significant to me, for over 90% of the operations I currently perform simply did not exist when I finished my residency."

Postresidency education is such a critical issue in light of modern laparoscopic accomplishments that it should become a central issue to our governing boards and societies.

The American Board of Medical Specialties created a task force to investigate competencies (163). They realized that they must adopt a method of reviews that would cover the training of physicians as a continuum from residency through retirement. "Depth as well as breadth can be discerned as physicians explore levels of expertise ranging from novice to master," states Leach (164) in a recent article. The Accreditation Council for Graduate Medical Education in 1999 endorsed six general competencies: patient care, medical knowledge, practice-based learning and improvement, professionalism, interpersonal and communication skills, and system-based practice. The "Professor," Sir William Osler (165), once stated, "the whole art of medicine is an observation... but to educate the eye to see, the ear to hear, and the finger to feel take time ... to start a man on the right path, is all we can do."

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