Leaders in Medical Education

Dr. Joseph B. Cofer, American Board of Surgery

Osmosis Team
Published on Jul 11, 2014. Updated on Invalid date.

Dr. Joseph B. Cofer serves as Chair of the American Board of Surgery. He is also a professor of surgery and surgery residency program director at the University of Tennessee College of Medicine (UTCOM) in Chattanooga. In the past, Dr. Cofer implemented Project Access, a medical assistance program for uninsured community members, and he remains an active volunteer today. He has also served as president of the Association of Program Directors in Surgery, where he became involved in medical education. We were honored to speak with him about his leadership experiences in surgical medicine.

How did you decide on medicine as a career?

My dad was an engineer, and I just assumed I’d be an engineer. My grandfather, my mother’s father, was a surgeon. Interestingly, his mother’s father was a surgeon in the late 1800s. I was always around medicine in the sense that I had a close relationship with my grandfather. As a young boy, I was able to witness his standing in the community in a little town in West Virginia, where I was born. He always appealed to me as a man of gravitas, and I had great respect for him. But, I was going to be an aerospace engineer because I wanted to design airplanes. Very quickly I realized that that was not for me. It was way too technically complex with fluid mechanics, physics, and other subjects I really never enjoyed - so I changed my major to   industrial/systems engineering, which I enjoyed. During my last year in college, I worked as an IE for a factory in North Atlanta that made doors. They maybe had 60 employees total and didn’t have enough blue collar employees to justify a full time white collar engineering  staff. I worked maybe 20-30 hours/week around my classes, and later went through the job application process. I moved back home after graduation and was going to move to Dallas where I had accepted a job at Texas Instruments as an IE. I was a few days away from moving when I had an epiphany that I didn’t want to be an industrial engineer for the rest of my life and wanted to practice medicine.

I went to the pre-med counselor at UT Chattanooga, my hometown, and he looked at my overall college GPA (2.3) and said I’d never get into medical school. That made me mad, so I enrolled in UTC as a post baccalaureate special student, and the first semester I took 16 hours of biology classes and made straight As. I had discovered something I really wanted to do, and motivation is probably the main driver in life, with which you can do anything. It was really easy to do well at UTC because I really enjoyed what I was studying and I finally had a purpose, something I really wanted to do - go into medicine. To make a long story short, I eventually took the MCATs and did very well on them, though I still couldn’t get into medical school because of my total college career GPA. I got turned down from multiple schools - I still have those rejection letters that I've saved. I finally got a interview at UTHSC in Memphis and was accepted. I learned that if you want medical school bad enough, you can get in, short of perhaps being a convicted felon.

What made you pick surgery as your specialty?

My grandfather was a surgeon so I always thought I’d do it as well, but really when I got to my surgery clerkship I met my mentor, Dr. Phillip Burns, then and now chairman at the UT Chattanooga surgery residency. I have this theory I developed as I have interviewed medical students for my residency. I believe one goes into medical school and thinks they want to do this or that specialty, based on some preconceived notion. But my theory is that most medical students meet one specific person, resident/faculty member, and they decide “I want to be like that person”. That decision drives their choice of residency training. When medical students are specifically asked about this some 20-25% say it did not happen that way for them, but most say that it was personal interaction with a specific person that influenced their decision. So, that’s what happened to me - I met someone, a general surgeon, who I wanted to be like.

What made you decide to take on a leadership position?

When I was a surgery resident from '83-88, it was brutal. The work hours were terrible - a lot of the old guys may hate me for saying this. We were often on call every other night, sometimes for a week or two. We were here all night, up all night. I will never forget my Liver Transplant fellowship which was even more brutal. I left my training programs very well trained but with a bitter taste in my mouth. I decided that if I ever had a chance to change the way surgical education occurred, I would try to change things for the better. Several years later I got a bit burned out with the liver transplant lifestyle, was looking for a career change, and my old mentor, Dr. Burns, called and asked me to return to Chattanooga and become Program Director for the Surgery residency program.

Medical education is a special place to be. Think about it. You have a chance to influence young people, to teach them how they should treat other people. It’s a huge honor to be involved in medical education. I’m convinced general surgeons are the top of the heap - a biased opinion, of course. What a huge honor to train young surgeons, who wouldn’t want to do that?

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What is your day-to-day schedule like?

I’m on the road a lot giving talks to other surgical programs. It’s really changed my clinical practice because I’m frequently not in town. If you’re a surgeon, you better be in town because you have to see patients in the clinic to be able to have a good elective clinical practice. If you’re not in the clinic you can’t schedule surgery. In addition, serving as a Director of the American Board of Surgery (ABS) involves another 4-5 weeks a year of travel. Every Director goes to two board meetings/year one in June and one in January, each for 4-5 days. Then you have to give the oral exam 3x/year. On top of that you may also get appointed to another board, have other committee meetings, etc. That’s a big chunk of time. Sometimes when you get to be an older surgeon like myself, you get asked to travel and visit other residencies, give Grand Rounds, and speak to their residents..

What would you improve about surgical education if you could choose one or two things?

One thing that needs to be changed is that we need to move from where we are closer to where we were. The biggest problem I see in the education of medical doctors is the way the system has led to no accountability. Nobody owns the patient. I think the worst example of that could be the development of the hospitalist service. It used to be 20 years ago that an internist followed a patient from admission to discharge. We try to teach our young surgeons that you own the patient. We have surgical services seen almost every day by the same doctor.

I believe that what greatly influenced this change were the Duty Hour Reforms. The first duty hour changes in 2003 were, I believe, the right thing to do, but the second major change in 2011 created an atmosphere of low accountability. One of the big things the ABS has done this year is to engage with the ACGME to start the FIRST trial. Starting in July 2014 we’ve enrolled about 150 surgical residencies whose hospitals participate in the National Surgical Quality Improvement Program of the American College of Surgeons. Half will be randomized to the study group, allowing them to utilize the initial work hour reforms: 4 days off/month, 80 hours per week averaged over four weeks, no more than 1 in third night call. The other control group will utilize the current work hours rules. The study will run from 7/2014-6/2015. If we can show non-inferiority as regards surgical patient outcomes in study group as compared with the control group, then the ACGME has implied that we may be allowed to return to the original duty hour reforms. We are hopeful that we can show this. The argument that work hour changes were necessary for patient safety go back to 2003. I don’t think any rational surgical educator wants to go back to training for 110-120 hrs/week. But if you’re a young surgeon and you operate on someone and they start bleeding, you should be allowed to stay and take care of your patient. There needs to be some flexibility. I'm not saying that we go back to brutal, medieval training. But young surgeons have to understand the concept of ownership of the patient, a moral responsibility to the patient. I'm not saying you have to fly back from your vacation in Hawaii to operate, but being allowed to legally stay an extra two-three  hours to provide specific patient care will help make a better surgeon. Overall, I think we need to get away from the concept of shift work and reinstall the concept of patient ownership.