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Send to a FriendFor several years Thoracic Surgeons have grappled with the increasingly recalcitrant problems of sicker patients, diminishing reimbursement, shrinking research funding, decreasing educational support, and malignant bureaucratic encroachment. The impact of these events has been to make it more difficult to care for our patients today, to impede our ability to develop new ways to care for them in the future, and to hamper our ability to train the next generation of Thoracic Surgeons. After years of simply reacting to these external problems because we were all "too busy" to bother with them, we have now begun to confront them directly and specifically. In doing so, we have initiated the process of taking control of our own destiny as Thoracic Surgeons.
The specialty organizations that engage in the "care and feeding" of Thoracic Surgery may seem to be of little importance to the practicing surgeon whose main concerns tend to center around patient outcomes and increasing volumes. However, it is through these organizations that changes are being effected that have already impacted both the practicing surgeon and academic departments, and will continue to do so in the future. For example, the unrelenting attack by Medicare's Health Care Finance Administration (HFCA) on the reimbursement levels for coronary artery bypass surgery has been successfully blunted on several occasions in the recent past largely because of the aggressive posture taken by the AATS/STS Joint Committee on Government Relations. This effort has been spearheaded over the years by a variety of surgeons representing both the private and academic sectors of the specialty.
When raw, non-adjusted outcomes for coronary artery bypass surgery began to be published in thc lay press a few years ago, most cardiac surgeons recognized that the greatest threat that this kind of journalistic ignorance posed was not to just one individual surgeon but to the specialty itself. Cardiac surgeons quickly responded by establishing the most comprehensive surgical specialty database in the world. Previous attempts at risk stratification of operative procedures based on complex, frequently arbitrary schemes were replaced by the STS National Adult Cardiac Surgery Database, which has become the gold standard against which cardiac surgical results are now measured. Similar databases have been or are now being established for general thoracic surgical procedures and for congenital heart surgery.
Ten years ago the academic leaders in Thoracic Surgery recognized the threat posed by the decreasing availability of research funds coupled with the unfortunate demise of the Cardiac Surgery Branch of the National Heart, Lung and Blood Institute. Thoracic Surgeons responded by establishing The Thoracic Surgery Foundation for Research and Education. The Foundation was initially funded by several large gifts, one of which was the transfer of the entire $800,000 Evarts A. Graham endowment from the AATS to the Foundation as restricted funds. The Foundation has since become one of our most important sources of funding for young academic surgeons.
In addition, thc Foundation established a course within the Kennedy School of Government at Harvard to which future academic and non-academic Thoracic Surgeons can learn the intricacies of how best to deal with thc external, government-related problems that have so profoundly impacted our specialty in the past few years. In my opinion, it is a singular disgrace that less than 10% of the Thoracic Surgeons in the United States have been willing to support the Foundation financially, even though it represents perhaps our most important effort to gain the tools necessary to control our own future.
In direct response to the recognized need to adapt to the educational trends of the "information age", the CTSNet was established on the internet four years ago. Even for those of us who did not grow up in front of a computer, CTSNet has become an invaluable resource that has already improved the standards of our specialty. Indeed, if supported as it should be by all Thoracic Surgeons, CTSNet will become the primary source of information for our entire specialty internationally. It has the potential to render all previous forms of training and education obsolete. Few causes are more important to our future than being certain that the CTSNet remains not only sound financially but that is also remains under the control of the specialty of Thoracic Surgery, rather than evolving into a subsidiary of an individual academic institution.
All of these developments, coupled with the impressive strides made in the governing sciences of our specialty, document a renewed vibrancy in Thoracic Surgery. However, our leaders continue to demure when dealing with the one remaining issue needed if we are to gain control over our specialty and its future. Whether we as Thoracic Surgeons pursue careers that are predominately private or academic, cardiac or general thoracic, adult or pediatric, our common foundation is the residency training experience and the subsequent certification process that stamps us as competent to practice within our chosen profession. Until we take the necessary steps to gain control over the training and certification processes that produce Thoracic Surgeons, our potential as a specialty will not be realized.
When the first Thoracic Surgery training programs were established in the 1930's. they were essentially apprenticeships. By 1948, thc leaders in Thoracic Surgery recognized the necessity for establishing certain standards of safety and competence within the specialty and thus, the American Board of Thoracic Surgery (ABTS) was founded. Thc ABTS was initially an appendage of the American Board of Surgery and remained so until 1971, when the sheer scope and size of the rapidly expanding specialty of Thoracic Surgery demanded that it have its own independent Board. Similarly, the Accreditation Council for Graduate Medical Education recognized the need for a Residency Review Committee (RRC) for Thoracic Surgery, and that body was created to set and maintain the standards for the roughly 100 training programs in North America at the time.
The specialty of Thoracic Surgery has evolved dramatically, especially in the past 40 years, yet we adhere to the general training format of thc 1930's, fu11y three decades after a consensus was reached that our specialty deserved an independent examination board (the American Board of Thoracic Surgery) and training program certification body (the RRC for Thoracic Surgery). We persist in expending enormous time and effort in the early years of postgraduate training performing tasks and procedures that we will never use in our careers and that are of little or no value in the educational process that culminates in our becoming Thoracic Surgeons. We justify this time as being essential to the "maturation process" and to the development of the basic knowledge and technical skills necessary to perform surgery within the chest.
We should remember that this "maturation process" is being forced upon individuals who were invariably academic superstars by the age of 18, who completed four years of college and finished in the top 2% of their classes, and who, after four years of medical school, are then around 26 years of age. If by that time, these graduates wish to enter a specific segment of surgery, they should be allowed to do so, rather than being forced to spend an additional five years(!!) training in a specialty in which they will never practice. Indeed, it is essential that we recognize that today, General Surgery is in fact a specialty in the vast field of surgery and not the "Mother of all Surgery" itself. Thus, as Thoracic Surgeons, we should insist that the first few years of our training be devoted to learning the general principles of surgery, and not the principles of General Surgery. We should encourage and support thc efforts of the Thoracic Surgery Directors Association in developing a curriculum for the first 2-3 years of training in these general principles of surgery to complement the Thoracic Surgery Curriculum that is already developed. We should then initiate an aggressive process of implementing those curricula, preferably but not necessarily, within the framework of existing General Surgery and Thoracic Surgery training programs. Once that has been accomplished, the American Board of Thoracic Surgery should immediately make optional the prerequisite for certification by the American Board of Surgery. If an individual prefers to be "double-boarded" in both General Surgery and Thoracic Surgery, as we are now, he/she would sti11 have the option of doing so. However, the choice of entering Thoracic Surgery training without having completed General Surgery training would be available to that individual as well.
There are two major impediments to this suggestion. The first is that most academic General Surgery Departments in the country would have difficulty surviving financially without the income generated by their Thoracic Surgery Divisions. In addition, most academic institutions are organized with the three critical powers of appointment, space and finance being in the hands of the clinical Departmental Chairmen who are usually General Surgeons. This results, with very few exceptions, in non- Thoracic Surgeons making the crucial decisions that determine the scope and content of the clinical experience, research support and educational environment of our Thoracic Surgery trainees as well as that of the Thoracic Surgery faculty. Few General Surgery Departmental Chairmen are amenable to giving up the financial support and/or the power that would result from the formation of an independent Department of Thoracic Surgery in their institutions.
Thc second impediment is that the General Thoracic Surgeons (as distinct from Adult Cardiac Surgeons and Pediatric Cardiac Surgeons) within our specialty feel that accepting trainees who have not experienced thc Chief Resident year in General Surgery would be a mistake and would result in an inferior "end-product". That is a serious concern and one that should be addressed. However, there are potential solutions to this concern that do not resort to thc extreme of requiring all prospective Thoracic Surgery residents to spend five years in a General Surgery training program. For example, one consideration would be to differentiate the entrance requirements for trainees primarily interested in general thoracic surgery from those primarily interested in cardiac surgery.
Why is it important that we gain control of our training programs and our certification process? Because only by doing so can we address the most serious problem jeopardizing our future...the fact that the current graduates of our training programs have only a superficial knowledge of contemporary clinical cardiology, of the anatomy and physiology of congenital heart disease, and of the basics of pulmonary physiology, myocardial physiology, and transplant physiology. This suboptimal education is not the fault of the trainees. It is a failure of our training programs. There is simply too much to learn in the specialty of Thoracic Surgery in the year 2001 to confine our formal training to 2 years, yet we dare not extend what is already a burdensome and arduous training regimen. We must accept the fact that we need more time to train our residents adequately in adult cardiac surgery, general thoracic surgery and pediatric cardiac surgery than we needed 30 or 40 years ago. That extra time can be and should be recouped from thc 5 years of General Surgery training that are now required, and the sooner we do so, the brighter our future will be.