AFTER THOUGHT Halsteadian model

Back to the future

Halsted has the last laugh

By Deepak G Krishnan Cincinnati. USA

ALL OF US have a surgical lineage. A pseudo genetic heritage line that tracks our mentors to their mentors to their mentors and so on. I have a conspiracy theory that everyone is somehow linked to the Royal College of Surgeons in Edinburgh. Regardless of where we trained and what our scope or geography of our practice is, we are all linked to the Halstedian model of surgical training principles in one way or another.

William Steward Halsted was a visionary surgeon who pioneered some of the basic surgical principles changing the landscape of modern surgery1. Dwarfing all his other achievements was his contributions to surgical education. During his tenure as an academic surgeon, young surgeons could practice with the knowledge they had, or choose a mentor to be an apprentice if wanted to further their knowledge in specific areas. It was previously uncharted territory without rules, regulations, or guidelines. The scope and length of this mentoring period was determined by the trainee surgeon and rendered complete when they felt so. Mentors did not have rule books either. They had varying abilities and experience, leaving their apprentices with uneven experiences. The entire process lacked structure and had inherent biases.

Halsted changed it all as the surgeon in chief of Johns Hopkins. He expected his trainees to be 100% dedicated to the job, live in the hospital (hence the name resident), not have a life outside of training, preferring unmarried men, and training did not have a set time frame. Halsted decided if an apprentice was ready for independent practice. A key feature of structure was “graduated responsibility.” A pyramidal hierarchy of junior assistant residents, assistant residents, and eventually a single trainee referred to as simply, “the resident,” second only to Halsted who stood at the apex. As trainees advanced, they took on more responsibilities. Promotion was not a guarantee, and not every trainee progressed to the next level. Halsted probably was brutally selective picking only the best candidates for his residency and ensured that only the finest would finish. Fast forward to today’s OMS education model. Educators are at a crossroads trying not to get canceled by a generation of trainees with a different set of values, expectations and learning abilities while trying to continue to do their best to train them. Work hour restrictions, part-time residencies, wellness time and paternity leave have all become mainstay in resident education. Add to this is the “call of the siren” – more and more surgeons are narrowing their practices to the most economically lucrative procedures. Poorly reimbursed major surgery is forced into confinement in major academic medical centers. Ironically, the academic surgeons are producing a product quiet unlike themselves. This leads to a mismatch between expectations and reality and will shape the future of our specialty all over the globe. Even more ironic is the fact that the longer a trainee stays in training, the burden of education debt looms larger over them forcing them to pick up practices that will help tame it someday.

Do the brightest and the finest among our residents gravitate to the wrong end of the rainbow in search of the fabled pot of gold? The long shadow cast by their educational debt, hierarchical practice patterns, intense peer competition and pressures of keeping up with their social media appearances force the new generation OMS to make career choices that may not serve the profession and specialty in its quest to expand its dimensions and scope. In fact, they are diametrically opposing forces. The privilege that Dr Halsted had in picking his mentees and promoting none but the best, may not be practical or appropriate in today’s world. It might not be a stretch to suggest that every academic OMS wishes that they had those privileges that William Halsted enjoyed in picking and training a prodigy. ■ August 2022 iaoms.org 39