Individual and social concerns in American surgical education: paying patients, prepaid health insurance, Medicare and Medicaid.

The education of the U.S. surgeon was traditionally based on a system in which surgeons-in-training cared for a population of largely indigent patients in a setting of graded responsibility. To ensure an ethically appropriate bargain, senior surgeons served as mentors, assumed ultimate responsibility for the patient, and supervised the surgical care of the ward patient by the surgical trainee. During the 20th century, changes in health care financing challenged this comfortable accommodation between charity care and medical education. As others have also written, the introduction of prepaid health insurance plans such as Blue Cross/Blue Shield in the early third of the century, the rapid expansion of employment-based health benefits during World War II, and the enactment of the Medicare and Medicaid legislation under Titles XVIII and XIX of the Social Security Act all contributed to a dramatic reduction in hospital ward (i.e., service) populations. The tension between education and patient care remains incompletely resolved; the proper balance between supervision and graded responsibility for the resident is ultimately worked out on an individual basis. Newer issues facing U.S. surgical education, including the justifiable demand for greater transparency, are likely to upset this suspended truce and lead to renewed discussions about such fundamental concepts as the definition of the resident and the role of the patient in the education of future surgeons.