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Dr. Herndon, it is always helpful to just start with some history, some perspective. Can you please share from your experience how, specifically, feedback and how it is given and taken has perhaps changed over time. How had it been earlier? And how has feedback and autonomy maybe progressed over time in your experience through now multiple iterations of this residency?

Dr. Herndon: I was thinking about this last night, and it’s very interesting that when I was a resident, I was a resident from 1965-1970, and at that time there was no formal evaluation at all of residents. But we had evaluations on an ongoing basis, on a daily basis every day. So how did that occur? Well, it occurred with critical comments made by the faculty when you were making rounds, in front of patients, in the hallways. It occurred at morning reports in medicine and surgery and all the specialties where you would be subjected to critical comments about your evaluation of the patient or how you handled the patient the night before. It occurred in the operating room directly. In fact, you might even be asked to leave the operating room on occasion if the surgeon didn’t like your performance. So it was a very direct, very assaultive almost kind of evaluation that occurred on a daily basis. I don’t recall ever sitting down with the chairman of the department or the residency program director or any faculty really and discussing my performance. So in my period of 40 some odd years in this field, I have seen a total cycle change to what we have today where there is required evaluations by the faculty, which is very good, required evaluations by the program director at least twice yearly, as I understand it still, and as much feedback as possible.

But with that, I still see some issues that are concerning. And my issues of concern are: are the evaluations really appropriate and valid for the resident; are they really helpful for the resident to understand what he or she needs to improve on? I find that, in my experience, faculty have been a little reluctant to spend the time needed to fill these evaluations out, a little concerned about confrontation and having negative comments made, whereas they should be helpful and constructive. I also think that in my experience over the years, attendings have been reluctant to put comments in writing on paper, which is very necessary for a program director to be able to get a sense of the resident’s position in the program, how well they are doing, and importantly try to help them get them on track if they’re not on track. It’s supposed to be an iterative and helpful process for the residents.

So how do you all feel that, at the attending level, people can move into constructive criticism beyond the, you know, “you did a great job, you showed up on time,” those sorts of general feedback, and what can a resident do to perhaps solicit feedback in the most appropriate way that’s most focused?

Dr. Bae: I’ll just make one observation, and I think George probably has the most to say about this; Chris has a lot to say as well. It was fascinating hearing that perspective to me because it sounds like feedback as you had described it was daily and very iterative, and yet, perhaps, there was no pauses or time to reflect to give summative performance evaluations. And maybe the pendulum has swung to the other end now where a lot of it is summative, and perhaps we have opportunities to make it more daily and more iterative. It’s a tough balance to strike, and I know George you’ve worked on that a lot. 

Dr. Dyer: I think one way to kind of break this code, and part of what was happening in the days of Dr. Herndon’s training that is happening less now is to explicitly focus on the growing and developing autonomy of the trainee. So that’s a little bit of what’s been lost is the goal of residency is to make our trainees autonomous at the end. And we have a little disconnect as the societal expectation and understanding about what training is and what the role of a trainee is in a patient’s care has become both more public but in some ways less well understood and less well accepted. There is a real difficulty to take on the role of autonomous surgeon while still a trainee. And there has become something that’s forbidden or reluctant about that. Not that our trainees are ever left alone or unsupervised, not that medical care is ever compromised, but there is no way to make a trainee autonomous and competent at the end of their training without letting them practice, without giving them, in a measured graduated way, increasing role of competence.

And when you take autonomy out of the picture as the goal and instead you make up competencies where somebody’s tried in a sort of an artificial way to define what is it that makes a person able to be autonomous but doesn’t test the thing itself, which is autonomy and capacity to do the work we do, then I think something’s really been lost and to me that explains part of the swing from iterative and formative evaluation on a daily basis to summative evaluation that seems a lot more artificial.

So if you’re operating with somebody in 1966 and you say “go ahead and do this,” and the resident can’t do it, then it’s pretty clear to both of you right then like “I asked you to do this, and you just can’t.” Right? It’s formative; it’s immediate. And the reason that it works is because the goal for both of you is at the end of three more years, you’re on your own, you got to be autonomous. And so if we can keep our eye on that goal, I think it makes it much easier.

I don’t want to hog too much air time, but I’ll just say that’s one thing we are innovating with here to try to make it the explicit goal of our training. And there’s a very simple evaluation system that I know Rameez is familiar with from working with me as a resident where each and every operation, in real time, and each and every interaction with a patient, in real time, is evaluated on a scale of autonomy. How autonomous do I judge you to be able to be based on how you are today? And in real time that feedback is given back to residents, and I think that’s going to help a great deal.

Dr. DiGiovanni: I think, Jim, it was great to hear that many decade experience. It’s a great perspective. Historically, I agree we have not been very good at providing feedback. I also think residents could also be better at soliciting feedback, so it’s really a little bit of both. Generally, it’s been extemporaneous and unpredictable in nature, but I think that feedback can be taught and learned; it’s really an art form. And you have to be open minded about getting it, too. There was an article in the Journal of Graduate Medical Education a couple years back that basically showed that when you get to our level, believe it or not, we are some of the worst self assessors. So that really influenced me that article, and what I’ve done with residents is I love to start with “Well, how do you think you’re doing?” And sometimes the answers are quite surprising, but they’re often very insightful, and they help me provide better feedback. But I think in addition to, as Jim mentioned, doing it in the OR, and in the clinics, and on the spot, I think there also needs to be structured, protected time, private time where you can really provide honest feedback and have an exchange. And that needs to be built into the program, and we're all busy. We and the residents need to be reminded to provide feedback. We all want to give feedback, and the residents all want the feedback, but we’re all very busy. So sometimes it’s just out of sight out of mind. And we need to spend a little more time maybe of making sure that it actually happen, but it is certainly an important part of growth as George said

Dr. Herndon: You know I found that residents really have a pretty good self assessment of themselves. It’s the rare resident that really doesn’t understand the problems that he or she is having. That’s really rare in my experience anyway. They’re pretty sharp about where their strengths and weaknesses lie.

Dr. DiGiovanni: I also find that we need to find a better way to provide feedback and have feedback received in a way that never seems, what’s the right word, embarrassing or personal or vindictive because that would also really help. I sometimes find, for example, that young attendings are a little more reticent to provide overt honest feedback, and similarly I find that young residents are also a little more shy about wanting to really hear what their weaknesses are in the flesh, so to speak. And so I think that is also something else we can work on.

So do you think there are differences then whether in feedback or any other strategy between a smaller program or a larger, much more spread out program as you have experienced in sort of both types of residencies?

Dr. DiGiovanni: In terms of feedback, not really. I do think there are some significant differences. You know large programs offer tremendous, much greater opportunity and potential. But that comes with a number of greater challenges too, and it’s not just the size of the program, so to speak, but it’s also the number of residents, it’s the number of attendings, it’s the number of hospitals, it’s even the size of the city and how spread out everything is. All of those things add complexity to trying to teach and educate. Just you working so hard getting all of us in the same room? Right? That wasn’t easy. That’s a microcosm of what we’re talking about. We need to work on better ways to identify that time. You know it’s funny what I’ve noticed about, and I’m sure these guys have too, with national meetings now. They don’t ask you three months ahead of time. They ask you like a year and a half ahead of time because A) the odds of you saying yes are much higher and B) the odds of you building it in your schedule and then actually doing it go up so we also need to think about in terms of how we’re getting everybody together to educate.

Along the lines of autonomy and moving beyond feedback: so for Dr. Bae, if a resident feels like they are not perhaps having that measured, graduated increase in autonomy over time, because I know this is something in your operating room you’re very cognizant about creating that, but if a resident feels like that’s not happening in a way they feel it should be, what are some strategies a resident might be able to do to have that self assessment but also that frank communication with the attending to match the expectations.

Dr. Bae: And by autonomy I think you mean surgical autonomy?

In the operating room. Surgical autonomy in doing a case and moving from the seeing to the doing.

Dr. Bae: Yeah, so I’m happy to start. I’m really interested in hearing what everyone else has to say. Just picking up one thread from Chris and George I think had it in his head as well. I think one concept that is really important to emphasize is that feedback can be a very constructive and objective thing. You know it’s not George is giving me feedback as I’m a resident in his operating room. This is not a George versus Don. This is George and Don standing together and looking at a skill or a clinical condition. We want to be aligned and looking at and face the same direction instead of at each other.

Dr. Dyer: And a shared goal.

Dr. Bae: Correct. And so I think you know there are many different formulae. There are lots of different ways to do it. One process that I like that’s easy for me to remember is trying to make an objective observation. Make sure that it’s clear that we are advocating for each other and for the patient and then asking a question. So George might say to me “Don, I noticed that you put the stitch through the artery. I know you’re a caring provider, and I know you didn’t mean to do that. Help me understand why did that happen.” So all of a sudden, it ceases to become George versus Don. It becomes objective he’s advocating for me and he’s asking a question. To flip it around a little bit, that can happen in a very positive way, and that should be a two way thing as well. So if I’m a resident in the operating room, I’m looking for more feedback, I can in some senses use the same recipe, and it’s just one recipe. “Dr. Dyer, I noticed that you got that screw in on the first shot, and I want to be as good a surgeon some day as you are hopefully. Help me understand how did you do that. Help me be better.” So that can be a positive way to do the same observation-advocacy-inquiry method.

Getting back to your question also (one last point and then I look forward to other people’s feedback). I think in terms of getting more feedback, I think there is hardware things, structural/systematic things, and then there’s software. Right? So we can control mostly the hardware. We can try to make sure the goals of a rotation or the goals of a day or the goals of an operation are explicit. And therefore if they’re explicit, and we’re aligned in those goals, we can be much more purposeful not only in how we care for the patient but how we provide the feedback. Communication obviously is key, and I think Chris alluded to that; sometimes it’s not so easy. We’re busy. There are a lot of different priorities. We got to take care of the patient. There are real world considerations in terms of productivity, duty hours, external circumstances. So I think if there is purposeful goals that are explicit, and there is good communication, at least those are the hardware, those are the systematic things we may be able to control to nudge people in the direction of a little bit more feedback.

Dr. Herndon: Don, your last comment I think is very appropriate and that is the fact that what you’re describing is a very time consuming process. And surgeons are busy; residents are busy. They don’t seem to have the time for what you just described. You’re a very organized guy. I know that; I’ve seen you work. But a lot of people aren’t as organized as you. And somehow the faculty have to have that commitment to take the time to do all that you describe.

I also wouldn’t like to see myself in a situation where I comment to the resident “I wish you hadn’t put that suture through the artery.” I would hope that that could be stopped before that happened. But I also know that, and I just want to make one case as an example, where, because what you described doesn’t happen, sometimes residents are expected to do more than they’re really prepared to do. So, for instance, you know on both sides of the table (when the resident’s on the other side; you’re on the other side), you ask the resident “go ahead and put those pedicle screws in,” and they’ve never done it before, it’s a little tough on that resident on the other side of the table. Somehow you have to take the time, the faculty member has to take the time, like you say, to make sure they understand what the resident is capable of doing, not capable of, what their experience is, and then be on the other side of the table helping them when they do their first pedicle screw.

Dr. Bae: And that’s I think where purposeful goals that are shared and a little bit of pre communication or post communication can be helpful. You may choose to make a simple intervention. I’m going to try: “Dr. Dyer, I’m your resident today. I’m really hoping to get some feedback because I want to be better, and you’re a great teacher. Can we try, when we call for the Vicryl stitch for the subdermal, can we try asking each other, or giving each other, one piece of feedback?” Build something that’s a little bit systematized. It’s not going to take extra time. In between cases that’s usually kind of a relatively down time where people are talking about the Red Sox or listening to music anyway. Small, little steps I think can take us there.

Dr. Herndon: Good suggestion.

Dr. Dyer: So I’ll tell you one simple thing that we’ve done, and it relates to the answer I gave before about making a very structured pathway or describing a very structured evolution toward autonomy. And it is, I’m going to give a little brief description of what this theory is, but it works very well, and we’re already putting it into practice.

This was developed by a person named Jay Zwischenberger, who is a thoracic surgeon actually in Kentucky, and it defines arbitrarily, but in a way that I think you’ll find is very intuitive, the pathway to autonomy into four stages. So stage 1 is watch me operate. So show and tell. So you’re a medical student, and I’m just filling the air with words as we do the surgery, and I’m explaining what the operation is, and how it works. And you ask questions. I might give you small tasks to do, but basically you’re watching me operate. So stage 1: show and tell.

Stage 2 is total help. So that’s me operating with your hands. So I don’t expect or anticipate or require you to be able to be at all autonomous, but you’re going to learn by the muscle memory of performing the operation where I say cut on the dotted line. So that’s stage 2: total help.

Then partial help where the onus and the responsibility of the operation really shifts to the operating surgeon, to the learning surgeon, and they are directing the operation. They are filling the air with words, explaining their plan as it evolves. “Here’s the next thing I’m going to do. Here’s the next risk that I know is coming up. Here’s my plan for avoiding this artery or that other structure of interest.” And you remain at level 3 with the surgeon assisting you as long as you continue to show that you’re on top of it and really prepared. So that’s level 3.

And then level 4 is supervision only. So I’m required by rules to be in the operating room. So I’m not gone; I’m scrubbed. But now I’m the medical student, and to the extent that it’s safe for that patient at that time, you are taking me through the operation. And if the operation grinds to a halt, it’s because you weren’t able to keep it moving, and that’s as close as we can get to true autonomy, that moment that’s going to be like the day after residency when there’s nobody else there telling you what to do or drawing a dotted line for you to cut on. So stage 1, 2, 3, and 4.

And what I do now is to pre-negotiate with every resident, every time, what level is this case for you. I call it leveling the case. Since it’s a pretty intuitive scale, people understand it pretty easily. You can say beforehand “I think this is level 3. Okay. So show me your plan. Explain what it is.” And then as we progress through the operation, the resident stays in level 3 by continuing to give me the comfort that this patient is being well cared for and that they are capable of that level of autonomy. When they hit a snag, because we’ve pre-negotiated it, it takes a bit of the sting out of the change in level. So we look at each other across the table and say “You know, this doesn’t seem to be a level 3 anymore. Why do you think that is?” And it doesn’t take a long time, but we have a framework instantly that is based not on you stink, or you don’t care, or you don’t care about me, or I’m impatient. The framework is we defined autonomy and your pathway to it, and there’s an obstacle. And in a very objective way, we can say what is that obstacle and work around it. It may be that I take the operation back to level 2 for a little while, but the resident then knows that they’ll get it back. They have a confidence that this isn’t a punishment, and they’re not in the doghouse for the rest of the day, but we’re just working through the plan we agreed on in advance.

The last thing, and I remember this from my own training, is that it takes away the kind of parallel mental effort that the resident takes wondering whether they are exhibiting the right level of autonomy. Because if you don’t make it explicit, the trainee just doesn’t know how much control they should be taking of the operation. And so in their head, they’re thinking “If I call for the next instrument, make the next move, am I showing that I’m competent, prepared, ready to go? Or am I scaring the heck out of this guy because he doesn’t expect me to do these things?” But if you’ve made it explicit in advance, then all of that processing power is free to learn instead of to worry about whether you’re at the right level of autonomy or not.

Dr. Bae: I think it’s a great approach. I can’t speak to complex foot and ankle or a lot of adult procedures. I know in the pediatric hand world, that approach works very well. And you can unpack each case. Right? There’s incision; there’s dissection; there’s fixation; there’s closure. Each of those things can be leveled at a different way using the Zwischenberger stages.

Dr. DiGiovanni: Yeah, I think autonomy is really proportionate to independence, and I think independence is proportionate to exposure and experience, and I think exposure and experience are proportionate to mandated duty hours. You know they’re all related. And we are, as a society, expecting the same throughput with our residents that graduate despite, as compared to say twenty years ago, despite much less structured input. So, in other words, the learning today has to really extend beyond the duty hour. And part of that onus falls on us, and part of it falls on our residents. I think that there are a lot of factors, many of which George just elucidated, that go into autonomy. But what I think we need to understand is that autonomy is not a privilege; autonomy is earned, so the resident needs to want to become autonomous. Obviously all residents proceed at different rates, and I also think all attendings are able, at their particular comfort level and with that particular procedure, to afford autonomy at different rates. So there needs to be a balance between those in terms of conferring autonomy to a resident. But I think people need to understand that it’s not a rite of passage. It really is something that has to be worked on.

Dr. Herndon: George, what you described was to me was the first I’ve heard of that. It’s a very refreshing, innovative look at how to handle this problem other than just turning certain types of patients over to the residents to operate on unsupervised like it was in my day. So are you teaching this to all the faculty? Is this something that’s going on in the program now?

Dr. Dyer: I am. It’s our next big faculty development initiative.

Dr. Herndon: I think that’s terrific. Also I’d like to ask you, to be a bit of a devil’s advocate here: how are you handling the informed consent issue with the patient regarding these levels of autonomy you’re giving the resident?

Dr. Dyer: So that’s something I’ve thought a lot about, particularly in recent months given some of the things that have been in the news. It’s always been my personal requirement and policy to be very up front and explicit with my own patients about the role of trainees in the operation. So I say: “This is an operation that I can’t do alone, and this trainee is the best partner for me you could ask for. So they are the product of a super competitive national search for the very best doctors who are specializing in orthopaedic surgery in the country, and I’m proud to have this person working with me. Here’s going to be their role. Here’s what we’re going to do. Meet them; shake their hand, if you have questions, but understand that I can’t do this operation alone.” So I try to involve the patient as much as possible. And it’s the very rare patient who says they are not comfortable with that, as long as it’s explained.

Dr. DiGiovanni: And in fact in most cases, right, nobody does that operation alone. So if you were somewhere else, whatever surgeon you’re talking to, they’re still going to have some kind of help. And the help you have is great help

Dr. Dyer: That’s right

Dr. Herndon: The key point you made is you actually introduce the patient to the resident. I think that’s essential.

Dr. Dyer: And I introduce them as a partner, not as “the help” that you don’t know who this is. It’s important to do it this way.

From the residents’ perspective, I mean, people talk amongst themselves, and this level system, it removes the uncertainty. It creates objective measure that you know as a resident: “Look this is on me. This is the homework I have to do, and if I do it, this is the relationship.” And the fluidity during the case is incredibly helpful. It’s not a negotiation. It’s “well if you’re doing this, this is how we proceed. If not, this is how we proceed.” And each step goes up and down. So from the resident side, that is very helpful.

Dr. Herndon: It’s nice to see the attending and the resident not fighting over the knife, so to speak.

Right. The rules are laid out. There’s no question mark, so that helps.

Dr. DiGiovanni: I also think, Rameez, obviously fellows impact that entire equation as well. Right? That’s a very important thing to maintain a proper balance for because that impacts resident autonomy as well. And it shouldn’t.

Absolutely. A large topic I know certainly in our program is an ongoing discussion.

So maybe we’ll shift quickly towards the end away from feedback and autonomy. But this question a lot of residents have of everyone nowadays is hyperspecializing and being asked earlier and earlier to do so. So what is your advice to a resident entering, for example, a foot and ankle rotation where they know they’re going to be a spine surgeon as a PGY-2 or 3, and they’re going to do their foot and ankle rotation? How can one strategize, both for the faculty member and the resident, to really optimize that experience as opposed to it being a passage of time? And this is for anybody certainly. The basic problem of, as people specialize, does that affect the relationship in the operating room at all from the faculty perspective?

Dr. Dyer: I don’t know that it should. And this is going to sound like a platitude, but it’s really true. There’s nobody you can’t learn something from. And there’s no trainee you can’t learn something from as a faculty member either. I think what’s passed between the faculty and the trainee is not just the specific technical skill of a Brostrom repair, right? I mean there’s much more to it. There’s your manner with patients. There’s your handling of tissues. There's your philosophy of indications. There’s how you manage complications that inevitably arise. And all the rest of those things really, with the perspective of time, dwarf the details of the Brostrom repair. And so the residents who are paying attention I think find just a wealth of mentorship and guidance and great examples from every interaction and the other way around. If you write off the spine bound resident who comes on your service as an upper extremity surgeon, then you’re missing out. These are talented people who have thought about all kinds of aspects of surgery beyond just the spine.

Dr. DiGiovanni: I think the best way to produce, using your example, a highly skilled orthopaedic spine surgeon is to start with a highly skilled orthopaedic surgeon. I am still in favor of the general pathway to maintenance of certification. I think it’s nice to know a little bit about all these different fields because they do all dovetail at some point. I don’t think our patients come to us on this subspecialty island, and it’s just really not how they present, and it’s not how we take care of them. I would love to know that the spine surgeon we produce, when the patient comes in with the foot complaint, they know the difference between the foot complaint that’s related to actually a spine problem versus the foot complaint that’s actually a foot problem. And there’s really only one way to do that, and that’s with a somewhat grounded experience. You know college applications they talk about the key concept. “Well lopsided” is the term they use, so you know you’ve got some peaks and valleys. You’ve got some depth here you know. For me it’s foot and ankle; for Don it’s, you know, upper extremity, but both of us still have some other peaks and valley that are maybe not quite as deep, but we still have some basic knowledge, and I think that’s useful for orthopaedics as well.

Dr. Herndon: The broader issue here is being addressed already by the general surgeons, and we haven’t done that yet, and that is to define what is a core orthopaedic surgery program all about? What do orthopaedic surgeons need to know? Because you get boarded in orthopaedic surgery; you get licensed to practice orthopaedic surgery. So if you take the negative here, and you say well you’re not going to ever do a total hip or total knee because you’re going to be a spine surgeon, when you get out into practice five years from now, that may change, and all of a sudden you want to do total hips and total knees, but you have no training for it. The states and governments don’t know how to recognize that, and the public doesn’t either. So if we’re going to be a profession, we have to really discipline our own and require various skills of our membership In our profession, we have to have some kind of a core program I think for what an orthopaedic surgeon is and based on that core, then you can proliferate out into whatever speciality you want, but somehow we have to define that, and we haven’t done that yet.

So moving ahead, looking at the future, as our kind of final subtopic, and this is a little bit more philosophical: all of you are hand picked to be here certainly because you have invested quite a bit of time in full time academics and education. Yet none of you are compensated in any way, shape, or form for all of that time and energy that’s spent in this. As the field moves forward, as all of these outcome metrics, as all of these pressures are based on speed and efficiency and pure clinical outcomes as defined by maybe even external agencies, how do you feel there can be a sustainability or potentially an incentivization for good surgeons to remain involved in education? And this is sort of open to just anybody thinking about, as bundled payments and all of these things we all hear about, move forward. Where is the time, let alone compensated time for teaching?

Dr. Dyer: Is it alright if I answer your question in a different way?

Absolutely

Dr. Dyer: Because I don’t think any of us teach for the money. Right? This is already, to be frank about it, this already is costly. But it’s not a cost; it’s an investment. And it’s not just an investment; it’s a pleasure. And we all do it gladly. And so I don’t think it’ll ever be for us, for the committed teaching faculty, a question of where’s my money to do this? I think a better and different question to ask is: how will the university and the medical system and the hospital organize itself to prioritize teaching in the face of these other things? It’s really not going to come down to the individual teacher, but it is going to come down to the hospital. So if I can just tweak your question a little bit. When I am accountable to the OR efficiency committee for my throughput, and I am doing 10% or 20% less surgery per day than my practice matched peer because I am spending that 10 or 20% teaching, how am I not going to lose my block time and be penalized? And the hospital’s willingness to support that is something that has kind of been quietly overlooked yet. And so I don’t have the answer, but I guess I would switch it from paying me to making sure the hospital’s mission remains partly and explicitly a teaching one.

So building that into the structure?

Dr. Dyer: Yeah.

Dr. Herndon: I think George has touched on a new paradigm, if you will, about how to reward teachers and researchers. I never had that opportunity, and I agree with everything that George said about the profession of teaching, and how much we love it and don’t expect reimbursement; however it’s getting tougher and tougher for surgeons, financially, and I see nothing but restraints coming down from the economic system as we go forward.

I’ll just give an example of a creative way that I did at the University of Pittsburgh, which just gives you a model of how we should think before we get to George’s status, which I hope would happen, that the institutions would identify the problem and help contribute to solving the problem. Most academic departments have a taxation system of their faculty. As chairman, I put those dollars in a pool, and then I rewarded the teachers. Everybody didn’t teach fully, but I rewarded the teachers by saying “Okay if you’re going to teach half a day a week or you’re going to be in the lab half a day a week or a day a week, that’s 10 or 20% of what an average orthopaedic surgeon’s time is. Therefore you’re going to get some money from this pool equal to that 10 or 20% of the national average of an orthopaedic surgeon’s income.” And for the researchers, to incentivize research, and believe me financial gain and other kinds of gains are very important incentives for people, I negotiated a situation with the institution to take 10% of the indirects and give those back as rewards to the PhDs doing research. So a small bonus at the end of the year made them extremely successful in their determination to get federal funding. So incentives are important, and in the past individual department chairmen had to create those incentives. And the ones that had been successful did so; the others did not. But I like George’s attitude: we’re all in this game together. Somehow the medical school, the hospitals, all the academic institutions have to come together to try and address this issue. It’s very important. People can donate their time, but there becomes a limit on how much time you can donate.

Dr. DiGiovanni: I think what everybody is saying, at least my impression, is that we need to redefine what it is we value as a profession in medical education, and that’s going to be really, really important. And I think it may include some version of a comp plan, objectively as Jim is talking about. It may include how we apportion block time. It may include how we advance to professorship tracks or how we offer research support. There are a lot of ways to do it. It may be how we learn how to choose and retain the right people at an academic medical center. Not everybody is cut out for an academic medical center. And/or or maybe repurpose people who are here but maybe they aren’t that genuinely interested or dedicated to resident education. Maybe we can have non-teaching tracks or something. I mean there are a lot of different ways, but we definitely have to, as a group, address how we value and what we value in terms of being at a place like this.

Well thank you all very much for being here, for sharing your thoughts, for going over this topic with all of us today. I think we touched on a lot of the key points and subtopics. Obviously this is a very vast topic. We haven’t even broached things like measuring education and all the outcome end of it, but I think this helps shed some light on the process side. I look forward to an ongoing dialogue in our program and elsewhere, and I just want to, once again, want to thank you all for being here today.