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Send to a FriendCardiothoracic Surgery is a relatively young field. Its history has been extremely exciting through the work of many international leaders and innovators. I doubt that any other discipline has changed as rapidly as ours. In the previous few decades, cardiothoracic surgery did well. Academic institutions were prospering and NIH ably supported research. Even if research could not get supported by external funding, it could be supported out of patient-derived income. Reimbursement was quite good. Cardiothoracic surgery was considered an honorable field and was high in the public profile. I doubt anything excited the public as much as heart transplantation, artificial hearts and infant surgery. Young physicians were excited to enter the field and many aspired to leadership roles. It was worth the time, effort, and years of training and toiling to become a leader in our field.
The pendulum has swung. In the United States, managed care and Medicare have certainly reduced reimbursement. In addition, there has been a decentralization of programs to keep up with the angioplasty desires of our cardiology colleagues. Thus, cardiac surgery was introduced into many smaller hospitals. Academic institutions have been under fire as a result of reduced profitability and active investigations by the Federal Government charging fraud and abuse. Cardiac angioplasty has developed dramatically with stenting improving the efficacy of angioplasty. Thus, coronary bypass surgery referrals are down.
Surgeons at academic institutions are pushed to be surgeons only. They are the engines that run the place. There is less time to do research and participate in the educational endeavors that have brought many people to academics. There is certainly less money from clinical programs for research. For young investigators, it is difficult to get research endeavors funded. In addition, there are reduced applications to cardiothoracic residency programs. There are certainly more profitable fields than surgery, particularly in this age of the Internet and excellent economy. The questions, therefore, are who will be the next group of cardiothoracic surgical leaders and will the specialty survive? I have had the opportunity to discuss this will Larry Cohn, as previous President of the American Association for Thoracic Surgery, as well as Tim Gardner, President-Elect of the American Association for Thoracic Surgery. We had a difficult time coming up with many individuals who are under age 45 who are clear future leaders in cardiothoracic surgery. We were certain there were more out there but we could not identify them. Clearly, the specialty is under fire. Therefore, we must be very aggressive to identify, mentor, and continue to introduce young surgeons into leadership positions. In addition, we must develop new solutions to the problems our specialty faces.
What are potential solutions?
- We must encourage young people to go into our field. We need to focus on medical students. As cardiothoracic surgeons, we have strayed further away from dealing with medical students. We need to do this both at academic institutions as well as in the private sector. Medical student rotation certainly could be encouraged.
- We need more leadership and academic training. There is no thoracic surgical organization that right now has its main mission developing the academic surgical leader. Clearly, the Kennedy School program has been available for individuals to learn business and leadership skills. However, this may not be enough. We need to teach research, education, and administrative skills to our future leaders.
- We must identify prospectively those individuals who are most likely to become leaders and innovators. The senior members of our Societies should identify for mentoring 20 to 30 surgeons who are under 45. They should be selected, trained, and primed for leadership positions. This is not to say that the appropriate honor of being an officer of a society cannot go to people who are older or deserving of such honors. Rather, there must be a mechanism for getting young people into action sooner. Clearly, everyone is getting the message that our specialty is having trouble. I have been involved in strategic planning for several of our organizations. However, strategic planning will be of little value if there are no future leaders and academic surgeons.
- Finally, there needs to be more central and long-lasting leadership for our specialty. Though we are a small specialty, we speak with many voices. We should seriously consider an Executive Secretary for our specialty as a whole with a prolonged term. The American College of Surgeons certainly has established this type of position. This would provide an individual that could lead our field in this time of turmoil. More importantly, such an elder statesman would be a role model for future leaders in our specialty.