Does diversity matter?

“We all should know that diversity makes for a rich tapestry, and we must understand that all the threads of the tapestry are equal in value no matter what their color.”

~Maya Angelou

I am not a poet and don't claim to have some great understanding of poetry. I do appreciate poetry and the allusions that many authors use to explain certain opinions. The Hollow Men, by T.S. Elliot, is one such poem. It makes many allusions and references to other poems and historical figures to explain his displeasure of society and war. Some believe that it is written from 5 different perspectives; each perspective representing a phase of the passing of a soul into one of death's kingdoms. This is a complex poem which requires an understanding of the time in which it was written, past history, and previous writings of both the author and other authors (such as Dante's Divine Comedy). As complex as this poem is, it is easier to understand than understanding another's perspective.

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Our perspectives are formed over time. We are affected by our upbringing and experiences. There is no denying this fact. Like our musical tastes, our perspective is shaped by our initial influences and changes with our experience. Differences of perspective is one of the reasons for the emphasis on diversity. Some believe this is a repackaging of "affirmative action", but in my view it is not. Diversity is about bringing together different perspectives. I have been avoiding this topic because it is a hot button issue. Now, with our current political race placing both a African-American man vs a woman and having seen a number posts in different forms that have mentioned the topic, I felt it was time.

Before I speak about diversity, I think I have to give you my personal perspective and history. Who am I? I am the great-great grandson of a Bishop of the AME church. I am the great grandson of a former president of Wilberforce University and one of Yale's first African-American graduates. The nephew of a Yale medical school dean and a descendant of Henry O. Tanner. My parents met at a Williams and Bennington college social function. In the 60's and early 70's, my father was very involved in both SNCC and CORE. In my youth, I grew up with Afro's and dashikis. I listened to stories about Medgar Evers and other leaders in the Black power movement. Yes, I am a black man.

I am the oldest in my family. I have a total of 5 sisters, 1 by marriage and 4 half sisters. I was raised in Wilkinsburg, PA and went through the Wilkinsburg public school system. Considered one of the smart ones, I was protected by many of my friends from some of the bad influences. At age 16, my best friend had his first child; he was 15. At age 18, I had mine. At age 19, my best friend was shot in the head, because he was selling drugs in the wrong area. Needless to say, I grew up in what some would consider a "rough" area.

If you look at my family history and my environment, you may say that they were at odds. In truth, it was always understood in my family that academics was important. There was an unspoken understanding that going to college was a given, which one was the only question. You see, the competition came from within the family, not outside. My cousins class rank of 2 bettered mine by 2 positions. My other cousin's SAT score of 1580 bettered my uncle's (her father) by 20 points. I wasn't that close. Although I grew up with gangs and teenage pregnancy, my overpowering influences came from history, family history.

For me, college was initially a culture shock, but I continued to do well. I majored in Biomedical Engineering and like many times in my life, I was "the only." For some reason, may be I had vision or laps of judgment, I decided to go to medical school in the second semester of my junior year. The prerequisites were made up over the summer, and the next year I applied to medical school.

For me, medical school wasn't that hard. It was a lot of work, but nothing was nearly as hard as some of my engineering courses. My medical school resume was pretty good. As I look back, it was not as good as I thought, but still it was pretty good. Because of concerns about this "affirmative action", I chose not to state my race on my application and did not provide a picture. It may have been a stupid move, but it was a choice I made at the time because I wanted to get there on merit only. Fortunately, it didn't hurt me. You see, because of my fair complexion, people usually can't place my race. It wasn't until I was a 3rd year resident that my chairman realized I was black. That still gives me a little chuckle.

Since medical school, I have been the only black resident, fellow, and faculty member. I am different in a number of ways. You can pick any one of the many things that makes me different. Whether it be race, family history, area where I was raised, or my marriage to a British citizen, I bring something different to the mix. There are people in my field that have the similar backgrounds, but not many. Can you now see my perspective?

Diversity is important. Different opinions and upbringings are important. Whether it be race, gender, or social status, it is important to have a heterogeneous population of physicians. Physicians that can relate to different patient populations. Be it a small town or the inner city, people from these areas tend to return to provide care in these needed areas. Patients also like to see people who are like them providing care. It is important that we mirror our population.

As I have seen and heard many times in the past, if a majority student doesn't get a spot and a under represented minority (URM) does, they wonder if they "lost a spot" to an under qualified URM. Well, let's look at the numbers. In a recent article in the Journal of the American Academy of Orthopaedic Surgeons, Templeton et al addressed the discrepancy in the percentages of URM and women between the medical school population and the orthopaedic resident population. The opening statement of the article states this:

Women and underrepresented minorities make up smaller proportions of orthopaedic residency programs than their numbers in medical school would predict, according to our evaluation of self-reported orthopaedic residency data from 1998 and 2001, as well as information on medical students published in 2002. Based on race, ethnicity, and sex, comparisons were made between students entering and graduating from medical school and those in orthopaedic residency programs. With few exceptions, the percentages of women and underrepresented minorities were statistically significantly lower among those training in orthopaedic residency programs compared with those same groups entering and graduating from medical school. The percentage of women and minorities in orthopaedic residency programs remained constant between 1998 and 2001. Further study is necessary to determine whether fewer students of color and women apply to orthopaedic residency programs becauseof lack of interest, lack of appropriate mentoring and role models, or other factors.

When I hear or read majority students make statements in relation to URM getting spots over a qualified majority students, I laugh a little. If you look at the numbers, there are far more white males competing than any other demographic. If you take a look at the tables from this article in 1998 and 2001, the discrepancy is incredible, especially for women. Majority students occupy 78.8% of orthopaedic spots in 1998 and 76.9% in 2001. The biggest discrepancy noted in the study is with women. The percentage of women in medical school was 44.3% of students in 1998 and 47.6% in 2001 with the percentage in orthopaedic residencies being 7.6% and 9.8% respectively. These numbers are not even close to the general population.

Even our national organization AAOS has started an initiative to encourage URM and women to apply to residency programs. The AAOS realizes that this is something that needs to change and they make this statement:

As the demographic face of our nation changes, the orthopaedic community is evolving to reflect and adapt to these critical shifts in the landscape. Recognizing the value and strength inherent in our diverse population is a first step. But our larger goal remains embracing solutions and mechanisms that give all people access to and a place in our healthcare system.

These are exciting times! The world is changing. Its face grows more diverse each day. The AAOS is committed to keeping, and setting, the pace. As our population grows rapidly more diverse, our need grows significantly for physicians who reflect this diversity and are accessible to communities and individuals with unique needs. The AAOS is taking the lead to ensure all people will be served appropriately by the field of orthopaedics.

Diversity is not just for the underrepresented populations, it is also for those majority students and physicians. It brings the different perspective to a program. Many may take care of these populations, but do they understand the perspective? Whether it be understanding the differences in the Hispanic cultures, or understanding the inner-city culture, having a diverse group of physicians helps everyone become more sensitized to all of these issues.

If we go beyond the clinical setting to research, there are diseases and conditions that are specific to certain populations. Issues like gender differences in bone structure and outcomes after total knee arthroplasty have created a new line of gender specific implants. There have been a number of studies that have looked at Ethnic and Racial Disparities in Diagnosis, Treatment, and Follow-up Care and Disparities in Orthopaedic Surgical Intervention; they have noted both racial and cultural differences. Who is more likely to investigate these conditions and issues than those who could or have been directly effected by the conditions.

Understanding that our numbers are low, how can we improve the numbers? One of the biggest problems is the lack of mentors. In my education, I lacked a "like" mentor. My mentors came from my "majority" physician mentors and my family. Looking specifically academic physicians, the numbers of URM or female are few. Nationally, there are powerful people who fit these groups. Dr. Rankin will be our academy president next year. In my own field, Dr. Crawford has been a leader in the pediatric orthopaedic community for years. The problem is that, if you are a URM or female student interested in my chosen field, it is hard to find someone "like" you who can share their experiences. If I look at my own background, I don't know if I ever could have found a mentor with the same history, but I don't think that was as important as finding someone that I could have related to. Be it cultural similarities or personal history, having a mentor who I could speak frankly about my fears and insecurities would have definitely helped me along the way.

Over the years, I have learned to adapt to my different situations. As such, I am able to view things from many perspectives. I have stated in this blog previously that I have tried hard to remain humble and approachable. Today, I put myself out there as someone that medical students and residents can relate to. I believe it is important that we understand our differences. Whether it be race, gender, culture, religion, or generation, we probably have more in common than we think.

T.S. Elliot writes a poem from 5 different perspectives. Like this poem, each physician/patient interaction is seen through multiple perspectives. The perspective of the patient with all of his/her fears and past history. The perspective of the physician and his/her personal experiences, as well as previous interactions with like patients. The perspective of the nurse and other physician extenders who bring their past history and experiences to view this interaction. Ultimately, understanding our differences is what helps make these interactions better. Regardless if it makes us color blind or more culturally sensitive, diversity ultimately makes us all better physicians.

“All truths are easy to understand once they are discovered; the point is to discover them.”

~Galileo Galilei

We all have our quirks ...

“The great aim of education is not knowledge, but action”

~Herbert Spencer

Looking back, residency was one of the best times of my life. Some of the experiences were priceless. I remember sitting in the resident's room and speaking with the other residents about the day. We would complain about the day. We would talk about the interesting cases that we had seen or done, what we had been accused of doing wrong (because we were always in the right), and what our upcoming plans were. Inevitably we would begin to speak about our "attending staff" and what they had said that day. We would commiserate about how we all had similar things said or done to us. I guess you could say after a while, some of the attendings became caricatures of their sayings and behaviors. If a resident would say a particular attendings "saying", we would all smile in acknowledgment. It was like an inside joke. Now, I am on the other end. I am one of the people that they mimic or mock. I guess we can't help it, we all have our quirks. It is fun to poke fun at people's eccentricities.

As an educator, it is important that you are self aware. We must understand out strengths and limits. To be effective at educating, we must understand what teaching style fits our quirks the best. I believe your teaching style should fit your personality, because the possibility of changing your general nature is slim to none. For instance, if you are not an outgoing and humorous person, you are not going to be that kind of educator. It is just a fact.

In evaluating myself, I realized I am a fire starter. Ok, that doesn't mean that I go out setting fires, but I like to look at things from the other point of view. I quite enjoy being the instigator. I do this during dinner conversations. My wife says she can see when it is coming because I get a little devilish grin. It is in my nature. I can't help it.

Usually when a resident comes to me with a plan, I like to take the opposing view point and argue that position. Even if I agree with the resident or medical students plan of care, I want to see if they have a reason. You may say that's mean. I don't know if it is, but it sure is fun. In truth, I want to see if they really understand why this is a good plan and aren't just parroting back what someone told them or what they read. I want to know that the understand enough to debate the subject. For example, a common debate I like to have with the residents is what type of graft to use for an ACL reconstruction, PROS and CONS. The resident usually fumble through this question because they usually haven't thought about it. Why do I ask it, because patients ask the same question. They need to have a good answer for why they recommend one over the other. Coming up with a plan is one thing, but being able to defend that plan is another.

I know we all have our quirks. I don't like a lot of futzing in the OR, I like foam in my casts ('cause it's cozy), and I like my coffee with cream and 1 Splenda ® (dam it). I say, "s/he's gonna love it," when I love it; and I say, "that makes me sad" or "that hurts my feelings," when I don't. If I am teaching, I want to see if the resident is actually thinking. The best way I have found to test someone's understanding of a subject is to debate of the topic. That's just how I roll. So, for now, I'll keep setting fires to see where it takes me.

“Tell me and I'll forget; show me and I may remember; involve me and I'll understand.”

~Chinese Proverb

More Interviews ...

“Sometimes questions are more important than answers.”

~Nancy Willard

It is our interview season. We had our first interviews a couple of weeks ago and I posted that I would ask the question, "tell me about yourself?" Well, I did ask the question, but I did modify it a little. The actual question I asked was, "in one sentence, tell me who you are outside of medicine?"

I also asked 4 other questions:

• What is your favorite book?
• Who is your favorite author?
• What is your favorite song?
• Who is your favorite music group, singer, or artist?

So, I ask you, my readers:

1. Do you think these are reasonable questions?
2. How would you answer them?

Thanks in advance,

Somonect

“Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.”

~Albert Einstein

Tying the attendings hands ...

“Wisdom is knowing what to do next, skill is knowing how to do it, and virtue is doing it.”
~David Starr Jordan

The 80 hour work week restriction has gotten a lot of attention over the past 5 years. Many believe that these are the only changes that have significantly affected resident and medical student education. Over the past 20 years there have been a number of things that have change the way physicians practice. As much as the 80 hour work week was a shock to the training system, there have been small changes in requirements for billing, resident supervision, and reimbursement, that have probably affected resident education in a more subtle way.

In the early 90's, many academic medical centers were evaluated by CMS and levied huge fees on a number of academic medical centers. From these evaluations, a number of new guidelines were set for billable encounters in teaching situations. The changes have require more of an attending presence in clinical and surgical procedures. Although this did not directly change resident education, it changed the attendings participation in patient care. The days of (billed) resident run clinics went away. The days of (billed) surgical procedures without attending presence are gone. These changes are good for patient care, but changed resident education. It increases the duration of the learning curve. There is no room for allowing the young surgeon to figure out how to get through the cases. I call this the "futz factor." Young surgeons need to "futz" to figure out what works best for them. With attendings present, they tend to become impatient with "futzing" and take over the case. Most young surgeons need to do, observation is not as helpful unless you have the experience on which to build. This change the resident attending interactions and cause many attendings to become more hands on.

Along with increased requirements for billing came a decreases in physician reimbursements. Decreases in reimbursements caused an increasing need for surgeons to become more clinically active. Department chairmans began to see the departments overall income decreasing. Systems to encourage increase clinical production (incentives) were set up. Now, you income became more like true private practice. The mentality of "you eat what you kill" began to creep into the mentality of new attendings. The days of seeing few patients, doing a couple of cases and getting a large salary are gone. With less overall (clinical) income, salaries became effected. It has caused attendings be like Snoop said, "with my mind on my money and my money on my mind."

The question may be posed, "why would this change resident teaching?" You would assume that more attending presence there should be better education. You would assume that more cases and more out-patient and in-patient experience would be better for resident education. Unfortunately, I don't see this as being the case. What I see is more patient being seen in clinic and less time for teaching. What I see is more cases being done with a limited amount of time, requiring more attending participation and less time to "futz". What I see in an increasing number of different procedures and increasing complexity of these procedures with less time to learn them. I see residents being over extended because of the increasing demand to produce clinically. I see the use of PA's and other physician extenders taking away residents ability to learn some of the basic skills, such as casting. With money being the driving factor, education suffers. Teaching does not pay, therefore education suffers.

So, as much as I harp on the "new generation" and on the 80 hour work week, I also think that our ability to educate well has also been affected. I think that we are not educating as well. Our ability to spend time educating our future surgeons has changed. We will have to develop new techniques for educating them. I fear things will get worse before they get better. I worry that we may be graduating future surgeons who are less prepared than in the past. Is this better for patient care?

“Real education must ultimately be limited to men who insist on knowing, the rest is mere sheep-herding.”
~Ezra Pound

Let's play the odds ....

“In all things it is better to hope than to despair”
~Johann Wolfgang von Goethe

The residency application year is about to begin and the same questions are being asked. "What do I need to score to get into an orthopaedic residency?" "Do I need research?" "How competitive am I?" I think these are the questions that we all had or have when applying to residency. I know I did. It seems like everyone wants the formula. If you have X honors with Z USMLE step 1 and Y letters of recommendation, you will be guaranteed a residency spot somewhere. I wish it were that simple.

I happened upon the statistics from last years match when looking through SDN. It was distributed by a young radiology resident trying to prove that they are as competitive as the big boys. I think he failed to actually look at the statistics and concentrated on the fact that the average USMLE step 1 & 2 score was 1 point higher than the average orthopaedic board score. But, that in itself does not make you competitive and I don't think that the 1 point difference reaches statistical significance. The competitive residencies have more applicants than spots, supply and demand. That is what makes them more competitive. So, he was a little misguided. I will give him the props that it is more competitive than I originally thought.

I think some of the interesting statistics from this report are that they looked at the the probability of matching based on USMLE score, number of programs ranked, and research and publications. They split things up based on U.S. Seniors in "other specialties" and in "Highly Competitive Specialties", and Independent Applicants in "Other Specialties" and Independent Applicants in "Highly Competitive Specialties" The highly competitive specialties are defined as specialties where the ratio of the number of U.S. seniors who ranked the specialty first to the number of available positions was 1 to 1 or greater. These specialties include: Dermatology, Orthopaedic Surgery, Otolaryngology, Plastic Surgery, and Radiation Oncology. This is an interesting document. It is all about statistics.

For those who want to know how competitive they are and want the actual numbers, this is the document you want. Good luck to you all.

“Doubt can only be removed by action.”
~Johann Wolfgang von Goethe

How do we educate residents with todays restrictions .... (part I)

“Whoever undertakes to set himself up as a judge of Truth and Knowledge is shipwrecked by the laughter of the gods.”

~Albert Einstein

When I was a resident, I really didn't appreciate what my attending had to endure. As we all tend to be, I was selfish in believing that they give me what "I" needed. They were not tending to "my" needs. Most of my thought were on me and my fellow residents. I had a belief that the "man was keepin' a brotha' down." As a system, I though it was built to maintain the status quo. Through our resident union, we even threatened to go on strike. As I progressed through residency and eventually became executive chief resident (otherwise known as the chief resident responsible for paperwork, schedules, and making nice between your residents and everyone else), I had more access to things outside of just my residency and became more aware of the political nature of the academic institution. This really opened my eyes to many things. My opinions of my older attendings changed. I realized that for the 20-30 years, they all had seen changes within the institution, residents and residency requirements, and the politically charged academic system. Most were acutely aware of what techniques were affective in helping a young surgeon to develop certain skills. Each had developed their own way of adapting their training style to accommodate the changes in the incoming generation.

The evolution of an orthopaedic surgeon from medical student to board certified orthopaedic surgeon is extremely complex. Understanding way of educating the surgeon is even more daunting. It requires an understanding of more than just a particular procedure and disease, but also require an understanding of the current generation and must be done within the restrictions of the environment of the time. All of our perceptions are based on our own experiences; so it "makes sense" that our teaching styles would be based on our personality and affected by educators that we found helpful in our own education. We currently are also working around restrictions set by the ACGME, RRC, and other governing bodies. As we try to come up with better and more efficient ways of educating the young surgeon, the resident's perception (in my view) is that we (educators) are not attuned to their needs and we only do things that are beneficial to us (attending staff). I do believe that many of the dedicated educators are more aware of what is needed to become a surgeon than you would probably think. So, how do we adapted to the system and current generation? Well, lets look first at some of the restrictions that are currently in place.

Most allopathic residency programs are under the guidelines created by the ACGME and the RRC. Residency programs must operate under the guise of the American Board of Orthopaedic Surgery, becaue our ultimate goal is to put out board certified orthopaedic surgeons. Most residency programs receive funding from the federal government; therefore, they are also affected by both medicare and medicaid regulations. The one restriction that gets the most publications is the hour restrictions. I may humble opinion, this does make educating a resident a little harder, but not for the reasons many think. The 80 hour restrictions have cause most residencies to react by hiring mid level provides to help or by employing moonlighters to cover shifts/call. For the most part, mid-level provides do not interfere with resident education but should help to make it somewhat more efficient. So, what are some of the restrictions?

ACGME and RRC

Through the ACGME and RRC, residencies are required to do several things for the educational component. These requirements must be uniform. One of the requirements is that there must be 4 hours of didactics that every resident in the program has access to. Service lectures do not count. The question then comes is when to you provide these didactic lectures so that everyone can attend and it does not interfere with the clinical education (surgery or clinic). Each program is also require to have a set number of months in the different specialties. In the near future, I foresee the requirements to even be more strict with require X amount of particular "key" surgical cases.

Medicare and Medicaid

Because hospital receive funding for residencies, there are several restrictions that were developed that directly effect surgical training. HCFA found that because medicare already paid for residents, they should not have to pay for care provided for a patient unless there was an "attending" that was directly involved with the care. With that determination, there went a majority of resident run clinics, and the amount of supervision in surgical residencies greatly increases. As time went along, even stricter rules began to develop with medicaid placing restrictions on the types of encounters that can occur at once. One restriction does not allow a physician to be involved in 2 separate clinical encounters at once without having someone who is completely free of clinical responsibility covering. You can not be both in clinic and in the OR at the same time. You can not run 2 rooms at once (with a resident) with out having someone who has no clinical responsibility covering you (that means they have no clinic or OR). This limits the number of things that can be done at once and by default decreasing the residents access to more exposure to both surgeries and clinical learning opportunities.

Hospital administration

Hospitals to have been effected by the medicare and medicaid regulations causing the hospital itself to create policies to ensure these guidelines are obeyed. Some facilities require the attending surgeon never to leave the operating suite. Dictations must be done within 24 hours. Surgeries can not begin without the attending surgeon being in the room. Many of these policy restrictions are definitely patient protective, but they do interfere with resident education and autonomy. The final thing you always have to keep in mind is that the Administration is always looking at the bottom line, things that interfere with that goal tend to get eliminated.


I could create giant lists of different rules, regulations, and policies that cause interference in the clinical educational component of resident education, but I just want to bring to light some of the restrictions that educator must work around to help educate residents. Next, I will look into the upcoming generation and what limitations educators have secondary to their experiences and perspective.

“Oppressed people cannot remain oppressed forever.”

~Martin Luther King, Jr.

My grampa is tall as trees ....

“I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
~Maya Angelou

My mother is a writer/poet. She wrote a wonderful children's short story that, I think, is fantastic and describes from a child's point of view how she looks up to her grandfather. Eventually, her grandfather dies and how she has difficulty believing that can happen because "My grampa is tall as trees." I feel this story emulates some of what may be occurring today in the academic world. See academics has always been seen as an area that is kind of sacred. It was the place that all of the "bad cases" were sent to. It was the place were the undeserved and uninsured could get care when the private physicians refused to see them. It was the place where you, as a physician, were told, "yes you may get payed less, but you will not have to work as hard as the private guys; you will have protected time to do 'academic endeavors'; and you will be respected for the 'specialty care' you provide." Times have changed.

"My grampa is tall as trees. Tough as tigers. Big as bears. When he walks the house rumbles and the china in Gramma's china closet shakes. I love mama more than peanut butter. But grampa is tall as trees"

In the past, orthopaedic surgeons at academic centers were protected from the world of billing. There was not as much of a concern for the costs of medical care. The expectation was as an academician, you were perfecting your craft. Part of your job was to search for advances in medical care. The clinical side was where you would practice your theory. You were told, "publish or perish." It was important that you taught others, spoke at meetings, get your and the institution's name out there. By speaking and teaching in and outside of your institution, you will gain prestige.

"Grampa's eyebrows are as big as clouds, and his wink is quick as lightning. Only I am fast enough to catch it. he always winks when mama makes a fuss. She tries to make him wear the new sweaters she buys him. The ones wihout the holes. Or make me wear dresses and comb my hair. I love mama more than biscuits and eggs with the juice runnin' out. But grampa is tall as trees."

The greats come from very academic institutions. They published papers and operated with residents. The did invited lectureships and taught new procedures. They were seen at the forefront of medicine. Academics is were the new ideas were born, practiced, and then released to the mainstream. Academicians became set in their ways. Doing things they way they have always done them without regards to cost. The clinical work both clinic and OR could be performed by residents. Trauma cases would be unsupervised while they continued to perfect their craft, either by writing or researching.

"In the mornin' I can smell cinnamon and coffee. The coffee is my mama. Grampa smells like cinnamon. I jump downstairs and try to rattle Gramma's china in the china closet, race through the room where no children are allowed, run into the kitchen and hop on Grampa's knee. Without a word. And I sit and watch him read the big black book. I know he's talkin' to God.

At many academy events, many academic physicians would present their research and speak in forums. There began to be a little shift with industry and some large group practices doing independent research away from the academic meccas.

The government reevaluated it's billion dollar insurance company (medicare) and realized that they should not pay twice for treatment of patients. "See we (government) pay residents already. So if only residents only perform the case, we will not pay and we will consider billing on those occasions fraud." This crack down place the academic and county institution under the spot light. It requires many people to adjust. They was more time to be spent directing are of patients and procedures and less time dedicated to research. "This was not that much of a problem I'll just do less research." For some, this was hard, but eventually they adjusted.

"Sometimes we take long walks and talk to trees and try not to step on cracks. Grampa tells me stories about the army ants that ate up a whole village of people. Just mowed down everything in sight. Millions of 'em. we sit under trees and wonder what they would say if they could talk."

In the position as educator, this physician had to educate both medical students, residents, and other physicians. This was part of their job. Many were baby boomers and had been trained under an iron fist and wielded their fist in the same manor. As political correctness came into fashion, out went much of the tolerance for the thrower and screamer. Write ups and visits to anger management discussing your feelings with your mother became more common. Resident physicians began to ask for the education. They want a handout with the lecture and they may ask why like a 2 year old child. Accepting what you say as gospel have gone to the way side. Learners actually want to learn from you and not just be a grunt. "Why can't they just do the work? It doesn't have to make sense, just believe what I tell you. Would I lie to you?"

"Grampa has two suits. One for Sunday. The other he never wears. he says he's savin' it for when he goes up in heaven to see Gramma a and have an important meeting with god. In the meantime he wears baggy overalls with lumpy pockets full of gum, his tobacco pouch, and a gold watch with a broken chain. She fusses about my overalls which are brighter and stiffer than grampa's and tries to put ribbons in my hair. I love Mama better than the honey apple raisin cakes from th bakery, but Grampa is tall as tress."

As times began to change, the pushes on the academic physician became worse. Cuts in insurance payments on basic procedures began to be noticed. The hospitals and practices began to reevaluate where money was being generated and were it was being lost. There began to be an encouragement to increase revenue by increase clinical flow. This again infringed on research time. At the same time that clinical practices were increasing, the amount of extended care providers and residents were not. The appeal for the academic practice began to decline. The politics within the university also was stifling. Creating more hassle than help.

"One night there was a big storm and the lights went out. It thundered and lightning and something bigger than Grampa shook the earth. Grampa said God was bigger than thunder and lightening and some people thought that when it stormed, God was angry. But Grampa said it was just his way of remind us that he is still here. Grampa says that God is old as dust, quicker than lightning, bigger than bears, and better than a bushel of honey apple raisin cakes WARMED WITH BUTTER."

In the private sector, things began to become more enticing. Specialty hospitals, surgery centers, and MRI scanners became a great money generator for the private physician. This made the financial difference greater and the attraction of younger physicians to the more profitable and less hassle private practice more appealing.

The government began to investigate the academic institutions for fraud. The restrictions for medicare and medicaid billing became increasingly tough. The possibility of a malpractice suit made the education of young minds more difficult. It require more supervision cause by the risk of malpractice and the restrictions governmental restrictions on billing. The physician who's life was once protected form many of the private worried by the academic system was now becoming more like a private practitioner without the financial rewards.

Learners, the residents, began to protest the previous work hours and ask for less hours. The ACGME placed restrictions on the resident work hour in response to the press and resident physician complaints. Educators where required to teach more and become more efficient at educating in less hours; as well as, increase the clinical revenue and produce publishable research. Why would anyone choose this as a life? There seems to be no benefit.

"Then on day I woke up and didn't smell the cinnamon or the coffee. I ran downstairs and didn't even try to rattle Grandma's china in the china closet, race through the room where no children are allowed, and went into the kitchen to jump on Grampa's knee.

But Grampa wasn't there

In his chair sat my Mama holding the big black book and looking at me with tears in her eyes. She told me that Grampa was ready to put on his suit and go up to heaven with Gramma to meet God. She said we could see him one more time in a church with all his family and friends. She said he would be in Godsleep and be Godstill. That means that his eyes would be closed for a long time and that he would be still and stiller than I can sit on Grampa's knee after he says 'In a minute.'"

As the practice of working in a university setting become more restrictive, it will have to adapt. It is extremely important that the educational structure begin to change to accommodate the changes in the system. We have to balance the differences between academic and private practice. The work load has become equivalent. The benefits of having residents are decreasing and sometime can be somewhat burdensome. The prestige of a academic physician that may have once been there is gone and can easily be overcome by the financial gains in a private setting. With many of the restrictions that have been imposed, it may become more difficult to replenish the numbers of academicians who are retiring.

"Now I can ride my tricycle past the prickly bush, all the way to Mr. Hammond's house and watch him cut the hedges. Mama's going to get me a bicycle with training wheels. And they finally came to carry away the old Dogwood tree that fell in the storm.

Now I talk to God even when there is no thunder to remind me. I say, 'Thank you, God for Mama, and Grampa and Gramma, who are with you, and my new friend, Mr. Hammond. and my brand new bicycle with the training wheels. Amen.'

And if I'm Still - almost Godstill - stiller than when I sat on Grampa's knee after he said 'In a minute, Sister' I can hear grampa smile and say.

'Good mornin' sister."

In the end, I think things will begin to balance out. As long as there are people willing to inspire, there will be people willing to be inspired. With that inspiration, maybe they to will wish to become an educator. Despite all of the restrictions with in the academic practice, the reward of helping others learn the craft may win over.

“Courage is the discovery that you may not win, and trying when you know you can lose.”

~Tom Krause