Introduction to Surgical Education
The University of Washington Department of Surgery:
Training Surgeons in the Pacific Northwest
The University of Washington began training surgery residents over 60 years ago. Since its inception in 1947, the program has focused on training excellent surgeons in the Pacific Northwest. Today approximately half of our graduates go into private practice and the remainder pursue careers in academic surgery. This reflects the unique partnership that was created in 1971 between the University of Washington School of Medicine and neighboring states, including Washington, Wyoming, Alaska, Montana, and Idaho, called the WWAMI Consortium (Wyoming joined the consortium in 1996). The Department has a dual role to provide trained surgeons for the urban and rural communities of the Northwest and prepare future academic surgeon-leaders. Graduates of the University of Washington surgical program that have chosen careers in academic surgery populate all major United States fellowship programs and universities. The Department and its affiliates offer an exceptional training program in all areas of surgery and extraordinary opportunities for clinical and basic science research. The clinical program is based at the University of Washington Medical Center, Harborview Medical Center, Veterans Affairs Puget Sound Health Care System, and the Seattle Children’s Hospital. The educational mission of the Department is to create surgeons who are clinically and technically superb while emphasizing continued learning, ethical principles, service, interpersonal relationships, and compassionate patient care.
The University of Washington Department of Surgery is committed to training future leaders in surgery in a collaborative and collegial environment led by a dedicated and distinguished group of Program Directors including C. James Carrico, E. Stan Lennard, Kaj Johansen, Clifford Herman, Hugh Foy, and, currently, Karen Horvath who was the recipient of the 2008 Accreditation Council for Graduate Medical Education (ACGME) Parker Palmer Courage to Teach Award. Our program consistently attracts the top 10 per cent of applicants from throughout the United States and strives for an exciting and progressive environment that fosters the intellectual development of students, residents, and practicing physicians alike.· We care about each individual in our program and view each resident as a valuable member of our surgical community. We focus on the development of the ‘‘whole’’ surgeon, emphasizing intellect, surgical skill, and humanity. Our program is designed to nurture and train each resident to achieve their full potential and career goals and place graduates into their top choices of fellowship and research programs or community practice.
Our motto is: examine, critique, and change what needs to be changed so that we keep the best of the ‘‘old school’’ while redefining the ’’new school’’ of surgical education in the 21st century.
The University of Washington Medical Center is a 450-bed comprehensive regional medical facility and tertiary referral center for the WWAMI region. It is nationally ranked among the top 12 medical centers in the United States as rated by U.S. News & World Report 2009 ‘‘America’s Best Hospitals’’ and most recently received top scores in eight of 16 specialties. The University of Washington Medical Center is one of the two major teaching hospitals for University of Washington Medicine and the site of a national Clinical Research Center and other major clinical research programs, including WISH and SORCE. It is also formally linked to the Fred Hutchinson Cancer Research Center through the Seattle Cancer Care Alliance providing surgery trainees state-of-the-art multidisciplinary training in oncology. The medical center provides residents with training in complex gastrointestinal, endocrine, and oncologic surgery and is the primary site for transplantation, cardiac surgery, and thoracic surgery.
Harborview Medical Center (HMC) is the only Level I adult and pediatric trauma center and regional burn center serving Washington, Alaska, Montana, and Idaho with a 351-bed facility. HMC is owned by King County, governed by a county-appointed board of trustees, and managed by the University of Washington. Since the inception of the medical school, HMC has consistently served as one of the two primary teaching sites for the University of Washington School of Medicine. This ultramodern facility provides residents with the unique opportunity to learn trauma care from the emergency room to the operating room, manage complex patients in the surgical intensive care unit, and provide all types of elective surgical care to our local underserved population. In 2002, Harborview provided $47.4 million in charity care and by 2007 the amount had grown to $124 million. Based on the last published figures from the Washington Department of Health, Harborview alone provides 21 per cent of all charity care in the state of Washington and 46 per cent of the charity care in King County. In addition, HMC has one of the world’s best burn units, top neurosurgical pavilions, and an outstanding plastic and reconstructive surgery center with extraordinary research facilities.
The Veterans Affairs Puget Sound Health Care System (VAPSHCS) is a 291-bed comprehensive tertiary-level facility that serves veterans in the Pacific Northwest region and is exclusively associated with the University of Washington (Fig. 10). The VAPSHCS is consistently ranked among the top 10 VAs in the country for research funding. Before the opening of the University of Washington Medical Center in 1959, the VAPSHCS served alongside HMC as the main teaching hospital of the university residency programs. Similar to the other institutions, the VA has contributed its own line of influential surgery leaders and educators, including Hub Radke, Richard H. Bell, Jr., and Michael Sobel. Residents currently rotating through theVA benefit from a wide experience in general and oncologicsurgery, vascular and endovascular surgery,cardiothoracic surgery, and critical care as well as providing opportunities in clinical and translational research.
Seattle Children’s Hospital is a 250-bed tertiary pediatric referral center for the WWAMI region affiliated with the University of Washington and is staffed solely by surgeons who are full-time University of Washington faculty. Children’s Hospital offers an extraordinary opportunity for learning pediatric surgery with world-renowned experts in numerous fields and over 13,000 procedures are performed each year. Residents also rotate through the Everett Clinic and Providence Regional Medical Center Everett, which is a 368-bed private practice facility that provides personalized instruction in all aspects of a community general surgery practice.
The General Surgery Residency Program at the University of Washington Affiliated Hospitals is an integrated 5-year program and accepts seven categorical residents and 20 preliminary residents each year. Like most university-based surgical programs, the University of Washington program provides a rigorous and comprehensive experience with graduated responsibilities designed to produce the highest caliber surgeon. It is intellectually as well as physically challenging with high expectations and standards for all of its trainees. At the same time, the program fosters a sense of camaraderie and accomplishment emanating from the collective talent and dedication of the entire department.
The R-1 is assigned to general surgery for 5 to 6 months and to the emergency trauma center at Harborview for 1 or 2 months. Experience in the burn center and in cardiothoracic, pediatric, orthopedic, urologic, and neurologic surgery completes the year. Responsibility focuses on initial evaluation and on pre- and postoperative care. The R-1 assists in operations on his or her patients and performs appropriate operative procedures.
The R-2 concentrates on the fundamentals of critical care with a primary responsibility in the intensive care units and in the Harborview Emergency Trauma Center. Rotations on various other services such as transplantation, surgical oncology, surgical consult service, and cardiac surgery broaden this experience. The R-2 performs operative procedures appropriate to that level of training.
The R-3 spends the year in general surgery at the VA and University of Washington Medical Center where advanced laparoscopy and bariatric surgery is the focus. A rotation as a senior fellow in medical gastroenterology augments the R-3’s knowledge and expertise in upper and lower gastrointestinal endoscopy. On the trauma surgery service, the R-3 experiences the primary responsibility of leading a team under the direction of a chief resident. This leadership role is reinforced on the burns/plastic service, transplant surgery, and pediatric surgery where the R-3 serves as the senior resident. A community hospital rotation at the Everett Clinic/ Providence–Everett Hospital completes the year. The R-3 performs major operations under close supervision. This early acquisition of technical ability permits a shift of emphasis in later years to the refinement of diagnostic sense, clinical and operative judgment, teaching skills, and investigative skills.
With the operative experience and surgical maturity gained during the R-3 year, the R-4 fine-tunes their knowledge and technical skills on both general surgery and subspecialty services. Rotations on general surgery, advanced gastrointestinal and hepatobiliary surgery, surgical oncology, and advanced laparoscopic surgery at the University of Washington Medical Center and vascular and thoracic surgery at the VA and HMC provide meaningful and rewarding clinical experiences.
The chief resident year provides major responsibilities in patient care, teaching, and administrative tasks. She or he performs the most complex operative procedures, supervises junior residents when appropriate, and assumes responsibility for the operative and supportive care of all surgical patients on the service. Chief residents enjoy a significant amount of decision-making latitude in the context of constant attending staff supervision. As leaders in the program, they also participate extensively in teaching students and residents, clinical investigations, and in departmental and service administrative matters.
This comprehensive curriculum encompasses both didactic and focused technical instruction provided through regular conferences, open and laparoscopic technical laboratories, and scheduled seminars. In July 2003, we developed a 4- to 8-week EVATS rotation for our surgical residents (Postgraduate Year [PGY]-1 procedures. through PGY-5) to provide time for emergency coverage, vacation time/coverage, academic time, and technical Summary skills training, which includes simulator work to refine both open and laparoscopic skills. The rotation was created to address ACGME core competency requirements and to enhance the educational experience of our training program within the restrictions of the ACGME 80-hour work week guidelines. Resident and faculty surveys have shown widespread enthusiasm and support for this innovative rotation. The nationally and internationally renowned faculty is committed to surgical education. Research time is not required but guaranteed to those who are interested. The Department encourages residents to pursue research in a variety of areas, including health outcomes, communication, leadership, and basic translational science. The Schilling Research Fellowship provides four 2-year research fellowships for surgery residents and there is additional funding supported by T-32 training grants in cardiac surgery/cardiology, trauma and health services research, and other sources available to those who are legitimately interested in research.
Over the past 5 years (2005–2010), 29 of 33 graduates pursued additional subspecialty fellowship training in top programs around the country in cardiothoracic surgery (6), colorectal surgery (1), endocrine surgery (1), minimally invasive surgery (3), pediatric surgery (3), plastic surgery (3), surgical oncology (5), trauma/ critical care (3), and vascular surgery (4). Ultimately, 90 per cent of our chief residents enter fellowship programs and 50 per cent eventually become faculty in academic centers across the country.
The General Surgery Residency Program at the University of Washington Affiliated Hospitals serves as the sole university training program in the Pacific Northwest, which encompasses a region representing nearly one-fourth of the United States land mass. We value our role to train excellent surgeons for the communities of the Northwest as well as mentor future leaders in academic surgery. The Department strives to stay on the leading edge of surgical education and continually seeks to improve the quality of the training program. We indeed feel fortunate to have the opportunity to train the best and brightest in one of the most exciting and rewarding professions in medicine.
Wu PC and Pellegrini C, “The University of Washington Department of Surgery: Training Surgeons in the Pacific Northwest.” Am Surg, 76(12):1321-7, 2010.