Reviving surgery with the smile, excitement, and Gemeinschaft concept: attempt at the Department of Surgery, Jikei University

Abstract Between 1994 and 2004, the number of surgeons in Japan declined by 18%, whereas the total number of medical doctors increased by 30% during the same period. This was due to the fact that the younger generation avoided tough working environments with long working hours. We attempted to revive surgery by reintroducing the good old Japanese community as the model under the slogan of “intimate community with excitement and sense of secureness”. In the absence of financial incentives, we were able to recruit young staff, and the number of surgeons at Jikei University has increased by 28% over the last 12 years and currently we have 280 surgeons. Our experience showed that although the younger generation is conscious about quality of life and financial success, they also value excitement, friendship, and happiness, something we were able to provide without financial spending. However, our success may be an exception and cannot be generalized; therefore, we should continue to strive to improve the surgeon’s quality of life by creating a better working environment, including sustainable work hours and decent financial incentives.

II Ohki: Reviving surgery with the smile, excitement and Gemeinschaft concept: attempt at the Jikei University Please judge the overall scientific quality of the manuscript. 4 Are you willing to review the revision of this manuscript? Yes

Comments to Author:
The paper briefly outlines the development of the surgical department at the Jikei University in Japan and describes the approach of the University to tackle the shortage in surgical staff and the lack of recruit surgeons. The author explains in detail how they achieved a significant increase in staff and improved the satisfaction and happiness of employees without financial incentives. He gives an inside into the three main components of their concept -smile, excitement and a feeling of belonging and empathy ("Gemeinschaft"). The presented developmental figures regarding the increase in staff are impressive and the story behind this success is written in a personal and empathic way. Given the shortage of young surgeons and the missing interest in surgery by medical students in almost all countries the topic is internationally of high socio-political relevance. Given the fact, that employee satisfaction was an imminent component of the presented concept itself ("smile") and of the desired outcome, evaluation data regarding this topic is missing. Although the impressive increase in staff over the years seems to be a proof of concept. Grammar and punctuation need some improvements from a native English speaking person.
In summary the topic of shortage of surgeons has been internationally discussed in the last years, proven by several publications. It would increase the quality of the paper if the own experiences would be discussed in the light of the existing literature and current knowledge.

Major Issues -Grammar and punctuation need improving
Minor Issues -From a scientific point of view the topic seems of minor interest -Evaluation data regarding the employee satisfaction is missing.
-How do the findings of the paper fit into the context of the existing literature and current knowledge?
The presented developmental figures regarding the increase in staff are impressive and the story behind this success is written in a personal and empathic way. Given the shortage of young surgeons and the missing interest in surgery by medical students in almost all countries the topic is internationally of high socio-political relevance. Given the fact, that employee satisfaction was an imminent component of the presented concept itself ("smile") and of the desired outcome, evaluation data regarding this topic is missing. Although the impressive increase in staff over the years seems to be a proof of concept. Grammar and punctuation need some improvements from a native English speaking person.
In summary the topic of shortage of surgeons has been internationally discussed in the last years, proven by several publications . It would increase the quality of the paper if the own experiences would be discussed in the light of the existing literature and current knowledge.

Major Issues -Grammar and punctuation need improving
Minor Issues -From a scientific point of view the topic seems of minor interest -Evaluation data regarding the employee satisfaction is missing.
-How do the findings of the paper fit into the context of the existing literature and current knowledge?
Response 1) Comment #1. "Grammar and punctuation need improving" I have tried my best to improve the English grammar and punctuation throughout the manuscript. Please see redline function of the revised manuscript. I would like to rely on the professional editing of the publisher. 2) Comment #2. "From a scientific point of view the topic seems of minor interest" although I agree with this comment, I was given this theme and title and was invited to submit this article and thus, cannot do anything about it. If the editors feels so, please reject this article. 3) Comment #3." Evaluation data regarding the employee satisfaction is missing" this is also a valid critique. Although I am not able to objectively prove that employee satisfaction has improved, in the view of the fact that many young surgeons joined our department in the absence of financial incentives or increase in salary, I believe that the fact that we were successful in recruiting young surgeons as shown in figure 1 is a circumstantial evidence that the staff surgeons are satisfied and happy. Otherwise, there are no other explanation for the success in young surgeon recruitment. 4) Comment #4. I appreciate for informing me of these related articles. I have quoted them and added the following paragraph in the discussion section, page 5-6.
"Shortage of surgeon is not only an issue in Japan but also is a global issue. In the US, unlike in Japan and Germany, the surgeons are paid well and the shortage is not solely due to unpopularity but is a result of ceiling of the number of surgical residency slots which is restricted by the Balanced Budget Act of 1997 and therefore the solution is different.8,9 On the other hand, Reid-Lombardo KM et al conducted a US national survey which revealed that improved reimbursement, lowering practicing cost, tort reform, national loan forgiveness program and solving lifestyle barriers may be effective in recruiting younger generation to surgery.10 With the exception of lifestyle barrier matter, most issues are US specific and do not directly apply to Japan or Germany and most EU countries. If one defines "surgeon shortage" as "general surgeon shortage" due to more young surgeons trained in general surgery advancing into subspecialty fellowships, then the solution may be different.9,11,12 Tierney J. et al proposes to extend the National Health Service Corps (NHSC) scholarship program to include general surgery. Since 1972, this program has been essential in building the primary care workforce in underserved urban and rural locations. NHSC provides scholarships and stipends to medical students who commit early in their education to residency training in primary care, followed by 4 years of service obligation in an approved underserved location.9 This creative approach may be effective in other countries including Japan, however, it is a long shot since it requires to create a large enough fund to incentivize surgical trainees to remain as general surgeons. On the contrary, our large department setting is not perfect but financially less burdensome. Although each staff surgeons at Jikei university has their own subspecialty and focuses on it while working at the university hospital, when they are dispatched to a related hospital which is smaller in size and often in rural area, more than often, they take the subspecialty cap off and practice as a general surgeon. We have mitigated the down side of super specialization with the unified large surgical department system and this approach may be an option where general surgery is in deficit."