Teaching Surgery as an Intimate Undertaking and a Personal Responsibility

Editor’s Note: The ACGME News and Views section of JGME includes data reports, updates, and perspectives from the ACGME and its review committees. The decision to publish the article is made by the ACGME.

Question: Who influenced you early in your career?

When I started in surgical education, it was Dr. John Landor. He hired me into my first faculty position at the fledgling Rutgers University medical school, after it developed to a 4-year campus and started residency programs. Before that, 2 years in the military had given me a sense what it was like to be a surgeon in a setting without residents. John was a role model. I admired his intellect – yet our personalities were quite different. He was the program director; I functioned as what would today be the associate program director. He had little interest in the details of the residency, and left most of the day-to-day running of the program to me. This was at a time when an American graduate applying to our program was a cause for celebration.

Tremendous changes happened in 1987 after the medical school moved its clinical operations from a small hospital to the urban site that is now the Robert Wood Johnson University Hospital. My mentor left, and the department head became program director. He ran the program into the ground with his focus on service and using the residency for political ends. Withdrawal of accreditation followed. I became the program director, and went through a site visit with 2 specialist site visitors, and got the residency reaccredited and back on track. I continued to be the program director until I moved to Stanford.

Question: Tell me about the move to Stanford?

In 2000, I came to Stanford University for the “job of a lifetime,” with an endowed chair and the position of chief of general surgery and director of the residency program. The program was in disarray, despite a wonderful institution and residents who were (and are) a cut above most places.

I arrived with the pledge to give Stanford the surgery department it deserved. It's worth noting that Stanford is different. In response to the question, “What is the difference between the East Coast and the West Coast?” I would say that on the East Coast everyone wants to be the best, wants to get ahead, perhaps even if that means walking over others. At Stanford everyone believes that they can all get ahead together.

Question: You have a deep interest in education? What is its origin?

My interest in education comes from two sources. One is the surgery chief residents at Yale I observed when I was a medical student. I watched them, and was in awe of them – their commitment to teaching, their style. I wanted to do that as well. The other source is my mother, who was a teacher.

Question: What makes the role of program director exciting for you?

Starting with my early years at Robert Wood Johnson Medical School, I have been happy as a program director. I had the ability to lead the program, and give the residents a sense that their needs were my highest priority. Surgery residents are bright, hard-working, and full of energy. In an academic surgery department, they are the greatest treasure. They also are pretty vulnerable. Working alongside faculty and other staff in multiple clinical sites can easily lead to them getting lost. It is the program director's job to protect them – to have their back. If that is done well, the returns are 100 fold.

I stepped down as program director in 2009. After a bout with lung cancer, surgery and chemotherapy, I was not enjoying the role as much as I did before. It was the right time to make a transition, and Tom Krummel took over the program. Do I miss being program director? Yes, I miss it a lot.

Question: Tell me about some memorable moments in your educator career?

One was my first accreditation site visit at Stanford. I had a sense that a lot of people were watching how the program would do, and it was gratifying that the Review Committee for Surgery gave us a perfect score and a commendation for the quality of the educational environment.

The second was when I stepped down as program director in 2009. Dr. Thomas Krummel, Stanford's department chair, named the final grand rounds of the academic year in my honor, at the request of the residents. I am a sculptor, and the residents gave me a large piece of marble. I just completed the abstract piece that will be placed at the entrance to the surgery department. It's a play on the letter “S.” It could stand for surgery or Stanford, or both. The piece seeks to capture the spirit of the gift of the marble.

Question: As you look at resident education today, what has changed?

The amount of regulation in residency programs has the consequence of both eroding the quality of education, and wearing out program directors. It takes time to develop as a program director, and a revolving door of individuals in the position has negative consequences. The program director must recognize that the residents are his or her highest priority – has to place their needs above faculty interests, and has to make it clear to faculty that these interests cannot detract from the quality of surgical education.

Question: Who influences you now?

Tom Krummel, who became the program director after I left the position in 2009, is an important mentor and influence. My wife, Dr. Irene Wapnir, a breast cancer surgeon, has had a tremendous impact on me. She has made me aware of the special needs of women in the surgical profession. Women have multiple roles – spouse, mother – in addition to being surgeons. At present at least one-half of the Stanford surgery residents, and 5 of 6 of last year's chief residents, are women.

Question: Some think being a program director is not rewarding. What advice would you give to this group?

For some, the program director position is not as highly valued. I watched this play out in my early days in education at Robert Wood Johnson Medical School. There needs to be recognition that the residency program is the life blood of the academic surgery department.

Being program director is not always a thankful task. What happens often is that the program director is faced with the enormous task of doing what is best for the residents. I always had a sense that this is exactly what I wanted to do. If faculty approach their role with a “where is my resident” mentality, perhaps they should not be on the teaching service.

The reward is that residents are like your children. If you do right by them, they will always come back. My illness told me a lot about what it means to be an important person in the residents' lives. When I was away for 7 months of chemotherapy and surgical resection of my right lung, I received daily e-mails and phone calls from residents and some visited with me at my home on campus. A resident came with her newborn child; another sent a CD with his favorite songs. I came to the realization that surgical training is special. It is very intimate. Standing at the operating table together, you get to know the residents very well; and they get to know you very well.

One of the biggest thrills is to watch a gifted chief resident operate, and to remember him or her as a surgical intern. It's similar to watching my 22-year-old son, in full flower, and remembering his grammar school years.

Question: What do you hope to accomplish with your recognition via the John Gienapp Award?

I would like to use it to increase the focus on surgery resident well-being and balance in their lives. In June 2010, a wonderful, accomplished “star” resident graduated from our program. I thought he was the best resident in many years. Four months later, in subspecialty fellowship in another city, he took his own life. Out of this tragedy, we developed an initiative entitled “A Program to Create Balance in the Lives of our Residents.” It's a comprehensive program that does just what the title suggests. I lead the program; residents love and appreciate it. The principle of the program is that we do an excellent job of teaching our residents how to take care of patients – now it is time to teach them how to take care of themselves.

With it, we have done everything we can to prevent an event like this from ever happening again. It's a comprehensive program and quite expensive – we estimate it costs $50,000. Perhaps not every program can do it. It's also very new; we implemented it in September and will get more experience with it. Whether through something like our program or by some other means, making sure that residents succeed, are protected, and have balance in their lives should be a central focus of the program director's work.

Dr. Greco is the Johnson & Johnson Distinguished Professor in Surgery and former general surgery residency program director at Stanford University. He is the recipient of the 2011 John C. Gienapp Award. The award recognizes individuals who have shown a life-time commitment and have made an outstanding contribution to enhancing graduate medical education. He was interviewed by Ingrid Philibert, PhD, MBA, Executive Managing Editor of JGME.