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Introduction Few educational programs exist for medical students that address professionalism in surgery, even though this core competency is required for graduate medical education and maintenance of board certification. Lapses in professional behavior occur commonly in surgical disciplines, with a negative effect on the operative team and patient care. Therefore, education regarding professionalism should begin early in the surgeon's formative process, to improve behavior. The goal of this project was to enhance the attitudes and knowledge of medical students regarding professionalism, to help them understand the role of professionalism in a surgical practice. Methods We implemented a 4-h seminar, spread out as 1-h sessions over the course of their month-long rotation, for 4th-year medical students serving as acting interns (AIs) in General Surgery, a surgical subspecialty, Obstetrics/Gynecology, or Anesthesia. Teaching methods included lecture, small group discussion, case studies, and journal club. Topics included Cognitive/Ethical Basis of Professionalism, Behavioral/Social Components of Professionalism, Managing Yourself, and Leading While You Work. We assessed attitudes about professionalism with a pre-course survey and tracked effect on learning and behavior with a post-course questionnaire. We asked AIs to rate the egregiousness of 30 scenarios involving potential lapses in professionalism. Results A total of 104 AIs (mean age, 26.5 y; male to female ratio, 1.6:1) participated in our course on professionalism in surgery. Up to 17.8% of the AIs had an alternate career before coming to medical school. Distribution of intended careers was: General Surgery, 27.4%; surgical subspecialties, 46.6%; Obstetrics/Gynecology, 13.7%; and Anesthesia, 12.3%. Acting interns ranked professionalism as the third most important of the six core competencies, after clinical skills and medical knowledge, but only slightly ahead of communication. Most AIs believed that professionalism could be taught and learned, and that the largest obstacle was not enough time in the curriculum. The most effective reported teaching methods were mentoring and modeling; lecture and journal club were the effective. Regarding attitudes toward professionalism, the most egregious examples of misconduct were substance abuse, illegal billing, boundary issues, sexual harassment, and lying about patient data, whereas the least egregious examples were receiving textbooks or honoraria from drug companies, advertising, self-prescribing for family members, and exceeding work-hour restrictions. The most important attributes of the professional were integrity and honesty, whereas the least valued were autonomy and altruism. The AIs reported that the course significantly improved their ability to define professionalism, identify attributes of the professional, understand the importance of professionalism, and integrate these concepts into practice (all P Conclusions Although medical students interested in surgery may already have well-formed attitudes and sophisticated knowledge about professionalism, this core competency can still be taught to and learned by trainees pursuing a surgical career.

The evolving surgeon shortage is occurring at a time of societal change. For one of the first times in history, a scientific revolution is occurring while the organization of health care is also changing. With a demand for a more quality health care and a population that has both aged significantly and grown by ten million citizens each decade, the shortage of health care providers is problematic. For surgery, the shortage is particularly challenging. In 1981, 1047 surgeons were certified by the American Board of Surgery; in 2008, that number had dropped to just 909.

Editor's note: This article is being published jointly in the Bulletin of the American College of Surgeons and the Bulletin of The Royal College of Surgeons of England. With health reform underway in both countries, the issues confronting the surgical workforce in the US are strikingly similar to the challenges facing the surgical workforce in England. This article describes the American College of Surgeons (ACS) Health Policy Research Institute's (HPRI) role in collecting, analysing and disseminating information about the surgical workforce in the US and suggests that HPRI might serve as a model for The Royal College of Surgeons of England to assist the UK government in workforce planning.

To examine variation in the practice patterns of individual general surgeons and how they differ between rural and urban areas of North Carolina.Traditional physician supply analyses often rely on "head counts" and do not take into account how physicians' practice patterns differ. Practice characteristics including the volume and the breadth of services that a physician provides may be especially important in understanding the supply and distribution of specialists, such as general surgeons.Cross-sectional study using physician licensure data linked with administrative records on all inpatient hospital discharges and all surgeries performed at freestanding ambulatory surgery centers in North Carolina in 2004.Total procedure volumes varied widely (interquartile range: 356-700). The average general surgeon in a rural county performed 54 different procedures at least once during the year, compared to 59 in counties with small urban areas and 62 in metropolitan counties. The 10 procedures that a general surgeon performed most frequently accounted for 72% of that surgeon's total annual procedures in rural counties, 67% in counties with small urban areas, and 66% in metropolitan counties. These rural metropolitan differences were smaller after controlling for secondary specialty and other surgeon characteristics.There was significant variation in the volume and scope of procedures that North Carolina general surgeons performed in the year. Many general surgeons in metropolitan areas performed an array of procedures that was broader than those in rural areas.

To estimate the capacity for supporting new general surgery residency programs among U.S. hospitals that currently do not have such programs.The authors compiled 2011 American Hospital Association data regarding the characteristics of hospitals with and without a general surgery residency program and 2012 Accreditation Council for Graduate Medical Education data regarding existing general surgery residencies. They performed an ordinary least squares regression to model the number of residents who could be trained at existing programs on the basis of residency program-level variables. They identified candidate hospitals on the basis of a priori defined criteria for new general surgery residency programs and an out-of-sample prediction of resident capacity among the candidate hospitals.The authors found that 153 hospitals in 39 states could support a general surgery residency program. The characteristics of these hospitals closely resembled the characteristics of hospitals with existing programs. They identified 435 new residency positions: 40 hospitals could support 2 residents per year, 99 hospitals could support 3 residents, 12 hospitals could support 4 residents, and 2 hospitals could support 5 residents. Accounting for progressive specialization, new residency programs could add 287 additional general surgeons to the workforce annually (after an initial five- to seven-year lead time).By creating new general surgery residency programs, hospitals could increase the number of general surgeons entering the workforce each year by 25%. A challenge to achieving this growth remains finding new funding mechanisms within and outside Medicare. Such changes are needed to mitigate projected workforce shortages.

A Festschrift honoring forty years of government services, twenty-five years as Founding Chairman of the Department of Surgery at the F. Edward Hebert School of Medicine of the Uniformed Services University of the Health Sciences, Bethesda, Maryland and the seventieth birthday of Norman M. Rich, MD, Facs, DMCC, was held on Friday 26 March, 2004 in conjuction with the 24th Annual USU Surgical Associates Day. This article describes that event and introduces the articles written in celebration of it. Open image in new window Figure 1 From a private collection. Open image in new window Figure 2 From a private collection.

The number and type of physicians required for a community isdependent on many unpredictable factors. The rapid change characteristicof twenty-first century society and the length of education required tobecome a physician add to the complexity of workforce projection.Peter Drucker, the economic futurist, described some periods of historyas times of ‘‘epochal transformation’’ [2]. These are periods in the world inwhich no one living could imagine the world in which their grandparentslived or in which their parents were born. Such periods were theRenaissance, the Reformation, and the Enlightenment. The Enlightenmenttransformed into modern society. Milestones in this transformationincluded the employment of movable type in Europe in 1450, the adventof the first workable steam engine in the early 1770s, and the United StatesDeclaration of Independence and Adam Smith’s The Wealth of Nations,both in 1776. An industrial society began to form that included thephilosophical radicalism of Thomas Paine and Karl Marx. Drucker labelsthe society of the late twentieth and early twenty-first century the‘‘knowledge society.’’ Ray Kurzweil, the 1988 Massachusetts Institute ofTechnology Inventor of the Year, predicted that the growth of technology inthe first 5 years of the twenty-first century will match that of the entire

Background Accreditation Council on Graduate Medical Education work-hour restrictions are aimed at improving patient safety and resident well-being. Although surgical trainees will be dramatically affected by these changes, no comprehensive assessment of their well-being has been recently attempted. Study design A multicenter study of psychological well-being of surgical residents (n = 108) across four US training programs before implementation of the 80-hour work week was performed using two validated surveys (Symptom Checklist-90-R [SCL-90-R] and Perceived Stress Scale [PSS]) during academic year 2002–03. Societal normative populations served as controls. Primary outcomes measures were psychologic distress (SCL-90-R) and perceived stress (PSS). Secondary outcomes measures (SCL-90-R) were somatization, depression, anxiety, interpersonal sensitivity, hostility, obsessive-compulsive behavior, phobic anxiety, paranoid ideation, and psychoticism. The impact of personal variables (age, gender, marital status) and programmatic variables (level of training, laboratory experience, institution) was assessed. Results Mean psychologic distress was significantly higher in general surgery residents than in the normative population (p th percentile and 72% above the 50 th percentile. Mean perceived stress among surgery residents was higher than historic controls (p th percentile and 68% above the 50 th percentile. Among secondary outcomes, eight of nine symptom dimensions were significantly higher in surgical residents than in societal controls. In subgroup analyses, male gender was associated with phobic anxiety (p Conclusions More than one-third of general surgery residents meet criteria for clinical psychologic distress. Surgery residents perceive significantly more stress than societal controls. Both personal and programmatic variables likely affect resident well-being and should be considered in assessing the full impact of Accreditation Council on Graduate Medical Education directives and in guiding future restructuring efforts.

Health workforce studies have mostly predicted an oversupply of physicians, a shortage of primary care doctors, and an excess of specialists. As the target date of many of these studies is now passed, it is clear that we are evolving into a shortage of physicians, especially specialists, and that primary care will increasingly be done by nonphysician clinicians. The "knowledge society" requires a different workforce than that predicted by most health planners.

The AAMC's Increasing Women's Leadership Project Implementation Committee examined four years of data on the advancement of women in academic medicine. With women comprising only 14% of tenured faculty and 12% of full professors, the committee concludes that the progress achieved is inadequate. Because academic medicine needs all the leaders it can develop to address accelerating institutional and societal needs, the waste of most women's potential is of growing importance. Only institutions able to recruit and retain women will be likely to maintain the best housestaff and faculty. The long-term success of academic health centers is thus inextricably linked to the development of women leaders. The committee therefore recommends that medical schools, teaching hospitals, and academic societies (1) emphasize faculty diversity in departmental reviews, evaluating department chairs on their development of women faculty; (2) target women's professional development needs within the context of helping all faculty maximize their faculty appointments, including helping men become more effective mentors of women; (3) assess which institutional practices tend to favor men's over women's professional development, such as defining “academic success” as largely an independent act and rewarding unrestricted availability to work (i.e., neglect of personal life); (4) enhance the effectiveness of search committees to attract women candidates, including assessment of group process and of how candidates' qualifications are defined and evaluated; and (5) financially support institutional Women in Medicine programs and the AAMC Women Liaison Officer and regularly monitor the representation of women at senior ranks.

In this issue, Kastor discusses the challenges and responsibilities of a contemporary chair of medicine as described in interviews of 44 chairs. As a chair of surgery at the University of North Carolina at Chapel Hill for 17 years, the author of this commentary uses his own experiences to reflect on how the insights presented in Kastor's commentary can apply to department chairs in other specialties. Elements from Kastor's commentary, as well as additional observations from the author's tenure, may be sources of advice to future chairs of any department. The author concludes that, despite a changing health care environment and other significant leadership challenges, being a department chair is a rewarding job with many opportunities to pursue worthwhile objectives.

Objective To identify trends and characteristics of surgeon employment in the United States. Surgeons are increasingly choosing hospital or large group employment as their practice environment. Design American Medical Association Physician Masterfile data were analyzed for the years 2001 to 2009. Setting Surgeons identified within the American Medical Association Masterfile. Participants Surgeons were defined using definitions from the American Medical Association specialty data and the American Board of Medical Specialties certification data and included active, nonfederal, and nonresident physicians younger than 80 years of age. Main Outcome Measures Employment status and trends. Results The number of surgeons who reported having their own self-employed practice decreased from 48% to 33% between 2001 and 2009, and this decrease corresponded with an increase in the number of employed surgeons. Sixty-eight percent of surgeons in the United States now self-identify their practice environment as employed. Between 2006 and 2011, there was a 32% increase in the number of surgeon in a full-time hospital employment arrangement. Younger surgeons and female surgeons increasingly favor employment in large group practices. Employment trends were similar for both urban and rural practices. Conclusions General surgeons and surgical subspecialists are choosing hospital employment instead of independent practice. The trend is especially notable among younger surgeons and among female surgeons. The trend denotes a professional paradigm shift of major importance.

Since 1990, society has been evolving through a period of significant transformation. In response to an increasingly information-rich and knowledge-based environment, the work force for most of society is becoming more specialized. Medicine is one of the few areas developing a work force which emphasizes generalism. For our current needs, the transitional work force has overproduced physicians. Because the overproduction has been uneven by specialty, it is deceptive to evaluate growth collectively rather than by individual subspecialty. Future shifts in age and types of illness combined with enhanced technology will transform the public's expectations of the American health care system. The type and number of physicians that will be needed in the future will be substantially different than in the past, so current patterns in physician education may not address the population's future demands.

OBJECTIVE To develop a projection model to forecast the head count and full-time equivalent supply of surgeons by age, sex, and specialty in the United States from 2009 to 2028. SUMMARY BACKGROUND DATA The search for the optimal number and specialty mix of surgeons to care for the United States population has taken on increased urgency under health care reform. Expanded insurance coverage and an aging population will increase demand for surgical and other medical services. Accurate forecasts of surgical service capacity are crucial to inform the federal government, training institutions, professional associations, and others charged with improving access to health care. METHODS The study uses a dynamic stock and flow model that simulates future changes in numbers and specialty type by factoring in changes in surgeon demographics and policy factors. RESULTS : Forecasts show that overall surgeon supply will decrease 18% during the period form 2009 to 2028 with declines in all specialties except colorectal, pediatric, neurological surgery, and vascular surgery. Model simulations suggest that none of the proposed changes to increase graduate medical education currently under consideration will be sufficient to offset declines. CONCLUSIONS The length of time it takes to train surgeons, the anticipated decrease in hours worked by surgeons in younger generations, and the potential decreases in graduate medical education funding suggest that there may be an insufficient surgeon workforce to meet population needs. Existing maldistribution patterns are likely to be exacerbated, leading to delayed or lost access to time-sensitive surgical procedures, particularly in rural areas.

Purpose General surgeons have decreased as a proportion of the total U.S. surgical workforce. Given the likelihood of increasing shortages of general surgeons, the authors evaluated available expansion capacity of existing general surgery residency programs. Method In November 2009, the authors e-mailed a Web-based questionnaire to the program directors and coordinators of the 246 U.S. general surgery residency programs that were then certified by the Accreditation Council for Graduate Medical Education. Results Of the 246 programs the authors contacted, 123 (50%) completed the survey. Community hospital programs and academic programs had similar response rates (52% and 50%, respectively). Of the 115 program directors who responded to the relevant question, 92 (80%) reported sufficient existing case volume capacity to accommodate additional surgery residents. Both community and academic program directors reported modest expansion capacity: an average of 1.7 and 2.0 additional residents per year, respectively. Across all programs, the average additional capacity reported was 1.9 additional residents per year. An expansion of this size would increase the number of general surgery residency positions from 1,137 to 1,515 annually. After accounting for subspecialization, this increase of 378 residents would result in approximately 249 additional general surgeons entering the workforce per year after five years. Conclusions Expansion capacity within existing approved general surgery residency programs is insufficient to meet the expected demand for general surgeons in the United States. Strategies to alleviate shortages include developing new training programs, cultivating new medical education funding streams, and changing the surgical training paradigm.

The debate over the status of the physician workforce seems to be concluded. It now is clear that a shortage of physicians exists and is likely to worsen. In retrospect it seems obvious that a static annual production of physicians, coupled with a population growth of 25 million persons each decade, would result in a progressively lower physician to population ratio. Moreover, Cooper has demonstrated convincingly that the robust economy of the past 50 years correlates with demand for physician services. The aging physician workforce is an additional problem: one third of physicians are over 55 years of age, and the population over the age of 65 years is expected to double by 2030. Signs of a physician and surgeon shortage are becoming apparent. The largest organization of physicians in the world (119,000 members), the American College of Physicians, published a white paper in 2006 titled, "The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care" [37]. The American College of Surgeons, the largest organization of surgeons, has published an article on access to emergency surgery [38], and the Institute of Medicine of the National Academies of Science has published a book on the future of emergency care (Fig. 10). The reports document diminished involvement and availability of emergency care by general surgeons, neurologic surgeons, orthopedists, hand surgeons, plastic surgeons, and others. The emergency room has become the primary care physician after 5 PM for much of the population. A survey done by the Commonwealth Fund revealed that less than half of primary care practices have an on-call arrangement for after-hours care. Other evidence of evolving shortage are reports of long wait times for appointments, the hospitalist movement, and others. The policies for the future should move beyond dispute over whether or not a shortage exists. The immediate need is for the United States, as a society, to commit to workforce self sufficiency in health care. The reliance on international graduates for more than 25% of the nation's physicians is a transnational problem. Reliance on IMGs, nurses and other health professions for the United States workforce is an issue of international distributive justice. Wealthy, developed countries, such as the United States, should be able to educate sufficient health professionals without relying on a less fortunate country's educated health workers. The 2000 Report of the Chair of the AAMC, the accrediting agency for United States and Canadian medical schools through the LCME, recommended expansion of medical school class sizes and expansion of medical schools [41]. For the past 25 years, the AAMC has supported a no-growth policy and the goal that 50% of USMGs be primary care physicians. In 2003, the AAMC developed a workforce center,-led by Edward Salsberg. The workforce center has provided valuable data and monitoring of the evolving workforce graduating from medical and and osteopathic schools in the United States. The NRMP, also managed by the AAMC, has begun useful studies analyzing the specialty choices of the more than 20,000 participants in the Match each year. The AAMC workforce policy was altered in 2006, and a 12-point policy statement was issued (see http://aamc.workforceposition.pdf). Three of the 12 points reflected significant change from past positions. They are a call for a 30% increase in physicians graduated by United States allopathic medical schools and an increase in residency positions now limited by the BBA of 1997. The recommendation that students make personal specialty choices reversed the prior recommendation that a majority of students enter primary care practice.

Arterial blood gas measurements (ABGs) are the most common tests ordered in an ICU. ABG utilization in a surgical ICU over a 1-year period (September 1, 1987-October 31, 1988) was evaluated to identify factors that might help reduce overutilization. A total of 842 admissions comprising 2,381 patient days were reviewed. ABGs were the most commonly ordered test (mean of 4.8/patient/day). Patients with arterial lines (A-lines) had more ABGs drawn than those who did not regardless of the value of PaO2 (p less than 0.01), PaCO2 (p less than 0.01 except for PaCO2 greater than 55), APACHE II score (p less than 0.01), use of ventilators (p less than 0.01), pulse oximeters (p less than 0.01), or a combination of the last two (p less than 0.01). Multivariate analysis demonstrated that the presence of an A-line was the most powerful predictor of the number of ABGs drawn per patient (p less than 0.0001) independent of all other measures of the patient's clinical status such as the use of ventilators, oximeters, and values of PaO2, PaCO2, or the APACHE II score. This suggests that ABGs are being drawn unnecessarily simply because of the presence of an A-line. To reduce the number of ABGs drawn, a policy for specific indications for placement of A-lines and ABG analysis should be adopted.

Healthcare in the 21st century will be characterized by an aging population, increased costs, and scientific and technological advances. It will be characterized by a physician shortage, especially of specialists. Healthcare will be increasingly provided by caregivers with a spectrum of diverse educational backgrounds other than M.D. graduates of United States medical schools, such as international medical graduates, Doctors of Osteopathy, and Non-Physicians Clinicians. General surgery and other specialties are attempting to clarify the roles and services that their specialties will provide. Designing modern undergraduate and graduate educational programs is key to planning for healthcare in the 21st century.

Background Although most general surgeons receive comparable training leading to Board certification, the services they provide in practice may be highly variable. Progressive specialization is the voluntary narrowing of scope of practice from the breadth of skills acquired during training; it occurs in response to patient demand, rapid growth of medical knowledge, and personal factors. Progressive specialization is increasingly linked to fellowship training, which generally abruptly narrows a surgeon's scope of practice. This study examines progressive specialization by evaluating trends in fellowship training among general surgeons. Study design Because no database exists that tracks trainees from medical school matriculation through entrance into the workforce, data from multiple sources were compiled to assess the impact of progressive specialization. Trends in overall number of trainees, match rates, and proportion of international medical graduates were analyzed. Results The proportion of general surgeons pursuing fellowship training has increased from > 55% to > 70% since 1992. The introduction of fellowship opportunities in newer content areas, such as breast surgery and minimally invasive surgery, accounts for some of the increase. Meanwhile, interest in more traditional subspecialties (ie, thoracic and vascular surgery) is declining. Conclusions Progressive specialization confounds workforce projections. Available databases provide only an estimate of the extent of progressive specialization. When surgeons complete fellowships, they narrow the spectrum of services provided. Consequently, as the phenomenon of progressive specialization evolves, a larger surgical workforce will be needed to provide the breadth of services encompassed by the primary components of general surgery.

PURPOSE To portray the professional experiences of men and women in academic general surgery with specific attention to factors associated with differing academic productivity and with leaving academia. METHOD A 131-question survey was mailed to all female (1,076) and a random 2:1 sample of male (2,152) members of the American College of Surgeons in three mailings between September 1998 and March 1999. Detailed questions regarding academic rank, career aspirations, publication rate, grant funding, workload, harassment, income, marriage and parenthood were asked. A five-point Likert scale measured influences on career satisfaction. Responses from strictly academic and tenure-track surgeons were analyzed and interpreted by gender, age, and rank. RESULTS Overall, 317 surgeons in academic practice (168 men, 149 women) responded, of which 150 were in tenure-track positions (86 men, 64 women). Men and women differed in academic rank, tenure status, career aspirations, and income. Women surgeons had published a median of ten articles compared with 25 articles for men (p

Background Medical students and residents often make specialty and practice choices with limited exposure to aspects of professional and personal life in general surgery. The purpose of this study was to portray practice composition, career choices, professional experiences, job satisfaction, and personal life characteristics specific to practicing general surgeons in the United States. Study design A 131-question survey was mailed to all female members (n = 1,076) and a random 2:1 sample of male members (n = 2,152) of the American College of Surgeons in three mailings between September 1998 and March 1999. Respondents who were not actively practicing general surgery in the United States and both trainees and surgeons who did not fit the definition of private or academic practice were excluded. Detailed questions regarding practice attributes, surgical training, professional choices, harassment, malpractice, career satisfaction, and personal life characteristics were included. Separate five-point Likert scales were designed to measure influences on career choices and satisfaction with professional and personal matters. Univariate analyses were used to analyze responses by surgeon age, gender, and practice type. Results A response rate of 57% resulted in 1,532 eligible responses. Significant differences between private and academic practice were noted in case composition, practice structure, and income potential; no major differences were seen in malpractice experience. Propensity for marriage and parenthood differed significantly between men and women surgeons. Overall career satisfaction was very high regardless of practice type. Some differences by surgeon gender in perceptions of equal career advancement opportunities and of professional isolation were noted. Conclusions This study offers a comprehensive view of general surgery to enable more informed decisions among medical students and residents regarding specialty choice or practice opportunities.

Accreditation Council on Graduate Medical Education work-hour restrictions are aimed at improving patient safety and resident well-being. Although surgical trainees will be dramatically affected by these changes, no comprehensive assessment of their well-being has been recently attempted.A multicenter study of psychological well-being of surgical residents (n = 108) across four US training programs before implementation of the 80-hour work week was performed using two validated surveys (Symptom Checklist-90-R [SCL-90-R] and Perceived Stress Scale [PSS]) during academic year 2002-03. Societal normative populations served as controls. Primary outcomes measures were psychologic distress (SCL-90-R) and perceived stress (PSS). Secondary outcomes measures (SCL-90-R) were somatization, depression, anxiety, interpersonal sensitivity, hostility, obsessive-compulsive behavior, phobic anxiety, paranoid ideation, and psychoticism. The impact of personal variables (age, gender, marital status) and programmatic variables (level of training, laboratory experience, institution) was assessed.Mean psychologic distress was significantly higher in general surgery residents than in the normative population (p0.0001), with 38% scoring above the 90th percentile and 72% above the 50th percentile. Mean perceived stress among surgery residents was higher than historic controls (p0.0001), with 21% scoring above the 90th percentile and 68% above the 50th percentile. Among secondary outcomes, eight of nine symptom dimensions were significantly higher in surgical residents than in societal controls. In subgroup analyses, male gender was associated with phobic anxiety (p0.001) and anxiety (p0.05), and junior level of training (PGY 1 to 3) with anxiety (p0.05), obsessive-compulsive behavior (p0.05), and interpersonal sensitivity (p0.05).More than one-third of general surgery residents meet criteria for clinical psychologic distress. Surgery residents perceive significantly more stress than societal controls. Both personal and programmatic variables likely affect resident well-being and should be considered in assessing the full impact of Accreditation Council on Graduate Medical Education directives and in guiding future restructuring efforts.

Arising from revulsion to the experiments conducted by Nazi doctors during World War II, the “Nuremberg Code on the Ethics of Human Research” in 1947 assimilated the legal and ethical conclusions of the deliberations of the Nuremberg Trials and established consent as the first of 10 principles of conduct expected of physicians in the performance of research involving human subjects. The long history of the ethics of research involving human subjects has evolved since then to resolutions in several areas. The concepts of different rules for therapeutic as opposed to non-therapeutic research, however, continue to blur and have now become nearly fused. Whereas in the past non-therapeutic research would presumably be less attractive than the implied potential benefit of therapeutic research, patients now view participation in research protocols as an opportunity—perhaps in desperation—to gain access to breakthrough medical science. The concept of consent continues to evolve. Consent, initially thought to be a recommendation, is now an absolute requirement. In a sense, it is the lasting and most significant contribution of the Nuremberg Code. The terminology has also changed, from “voluntary” consent to “informed” consent. Informed consent now includes understanding as well as being informed. The concept continues to expand into the requirement of autonomy for the participating research subjects. The complexity of modern science mandates a responsible regulatory system.

Modern medical care is increasingly dependent on the application of science to clinical practice, which occurs through clinical or translational research. We propose the concept of translational ethics, which incorporates the contributions of research codes of ethics that involve the protection of human subjects into the ethics of clinical practice. The modern research environment, which has contributed the scientific tools of modern medicine, has also framed the ethical environment in which medicine is practiced. The single most important contribution of research codes for protection of human research subjects to clinical practice is the doctrine of informed consent. Translational ethics, based on autonomy and informed consent, progresses beyond the narrow interpretation of those 2 concepts. It requires consensual understanding of a spectrum of clinical interventions that are increasingly complicated. Translational ethics helps navigate the ethical ramifications of technological and scientific advances that will increasingly challenge the corporate-oriented health system in the new millennium.