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Send to a Friend"The greatest discovery of my generation is that human
beings can alter their lives by altering their attitudes of
mind." - William James
Much has been said about the urgent need to change various parts of the graduate education process in thoracic surgery, yet one fundamental aspect of that endeavor that requires rethinking has received scant attention. By that I mean the set of attitudes and presuppositions that both resident and teacher bring to the table. A serious look at these attitudes of mind and how they have been--or can be--altered is necessary if we are to have continued success in our quest for the best residents to sustain our discipline.
The rush to make changes in certain aspects of the curriculum, such as the prerequisite requirements, the selection process, and the length of training, is predicated on presumptions and perceptions that may or may not be relevant or even true. One of the major motivating factors behind this movement for precipitous change is the recent recognition that for some time now, the number of residency positions available has exceeded the number of United States graduates who apply for training in thoracic surgery. Furthermore, over the past five matches, only about 75% to 85% of those U.S. graduates have matched, demonstrating that in many instances program directors prefer international graduates. Although these observations are accurate, their relationship to some of the changes being proposed is tenuous at best.
A simplistic analysis of this situation is as follows: 1) The problem is fewer applicants; therefore, we must be getting a less qualified resident. 2) The cause is that the residency is too long and too costly. 3) The solution is to shorten the residency. This stream of thought leads to a cascade of potentially devastating actions that could undo many of the marvelous advances that have occurred in residency education in thoracic surgery over the past decade.
How do differences in attitudes play into this scenario? Many of the senior surgeons occupying leadership roles in our specialty entered the field when it was very new or was evolving so rapidly that it appeared as an endless series of miraculous innovations. By comparison, other fields of surgery were almost quiescent. As James Le Fanu, the noted science writer, recently observed, "In the five years from 1955 to 1960, the pump transformed cardiac surgery into much the largest and most sophisticated of all surgical specialties . . . "[1] How could anyone with a sound mind and an adventuresome spirit not want to go into thoracic surgery?
Apparently some of today's applicants are resisting that imperative, as we are seeing fewer of them. Why is that? Is the residency too long and costly? Having spoken to that issue elsewhere,[2] I will not repeat myself except to say there is no objective evidence to demonstrate significant dissatisfaction with the length of training that is now required, nor with the level of indebtedness incurred, as great as it may seem to many of us. Extensive surveys completed in 1992[3,4] and 2000[5] failed to demonstrate that length of training was a major source of unhappiness. Indeed, the resident's attitude may be interpreted as demonstrating a contrary point of view. Regardless of the fact that "only" seven years of training are required, those responding to the surveys took an average of 8.6 and 9.1 years to finish training. They seem to accept the idea that this is serious work for which they are preparing. It may be that they intuitively understand what the learning literature suggests, that is, that mastery of a top professional domain requires about ten years of experience.[6] Furthermore, the respondents did not identify economic pressures as an overriding issue. Their acceptance of a certain amount of indebtedness, if it affords a more reasonable lifestyle, is more consonant with modern attitudes than those of their senior colleagues who are apt to have been born during the depression or war years. Thus, areas of concern for the modern resident tended to be focused more on the qualitative aspects of the experience than on time or economic elements.
Therefore, one change in attitude that will be helpful is for senior surgeons to worry less about the length of training or resident indebtedness and concentrate on continuing to improve the content of the curriculum. The resident's attitude is rather well attuned to what is required in the time domain, so those of us brought up in a different era need not be overly concerned about something our residents seem to handle rather well. Relieved of that guilt, the leadership may be less prone to engage in precipitous, ill-advised action.
If not length of training or financial constraints, are there other considerations that might illuminate this diminished interest in thoracic surgery? One obvious explanation is the changing applicant pool. Thirty or forty years ago, when many of our present leadership were applying for residency training, women constituted only about 6% of medical school enrollees. That number has increased more than seven-fold.[7] If thoracic surgery continues to draw from a predominantly male pool and that population has been almost halved, then simple arithmetic can account for much of the change. Although we appear to be recruiting excellent residents, as reflected in the resident surveys, one must seriously question how long that will be possible if we continue to overlook one-half of the potential applicants. Whereas general surgery and the other general surgery-based specialties are able to fill about 20% of their residencies with female candidates, we cannot seem to break much above the 5% mark (average for 1988-1996 = 3.3%).[8] It is my opinion that an attitude problem is at least partly responsible for this state of affairs.
At one of our recent intramural housestaff conferences, our speaker, a world-renowned virologist, began by saying that as a medical student he had wanted to be a thoracic surgeon. He was greatly influenced by the chief resident on the cardiac service of a major teaching hospital. This resident was intelligent, willing to teach, and an all-around good fellow--if a little older. One day, with little to no provocation, one of the senior cardiac surgeons dressed down this resident in a public setting "as if he were a schoolboy in knee pants." Our speaker and his classmates who witnessed this scene were appalled, and all agreed that they would not enter a field where that sort of behavior existed. It is my opinion that few men and no women at all will knowingly expose themselves to such abuse. Clearly an attitudinal change is needed to rid our ranks of such unacceptable deportment!
Another presupposition that underlies concerns about the decreasing number of applicants is that "these people don't want to do all that general surgery." I believe that just the opposite is true. I believe that present-day aspiring surgeons recognize that a broadly based education in surgery is greatly to their advantage. They are acutely aware that no one knows what the practice of surgery in general, or thoracic surgery in particular, will demand of them twenty years from now.
A few years ago, the number of applications for anesthesiology residencies dwindled to almost zero. This was in response to a growing awareness that the field was saturated and that few anesthesiologists were going to be needed in the foreseeable future. Perhaps we are experiencing a similar situation in our field. No one knows whether the United States needs 145 new thoracic surgeons each year. That historically rather constant number of residency positions is not based on any sure knowledge of the need for thoracic surgeons. Possibly in their wisdom, the modern surgical candidates realize that our discipline requires fewer than that now and probably even fewer in the future.
This insight on their part may be based on the almost certain knowledge that coronary artery surgery, as it is now practiced, has a limited life expectancy. Previous comparisons of revascularization versus medical therapy [9] are inapplicable today because current medical therapy includes lipid-lowering agents and inhibitors of angiotensin converting enzyme.[10] Indeed, in a recent report, Pitt et al concluded, "In low-risk patients with stable coronary artery disease, aggressive lipid-lowering therapy is at least as effective as angioplasty and usual care in reducing the incidence of ischemic events."[11] It is not farfetched to suggest that the situation in thoracic surgery may be analogous to that experienced by modern urology. As recently as 1987, more than 400,000 transurethral resections were being performed each year. That number has shrunk to about 70,000 per year as a result of the increasing use of alpha blocking agents and other less invasive forms of treatment for benign prostatic hyperplasia. Given the uncertainty surrounding the "signature" operation of our specialty, is there any wonder that potential thoracic residents may question the future of our field?
Addressing these concerns of our applicants in a thoughtful and constructive fashion will also address the concerns of those who are alarmed about the seeming loss of popularity of our specialty. Eschewing "silver bullets" such as shorter residencies, disassociation from general surgery, or matching out of medical school, the leadership in our field must thoughtfully consider the real issues that confront us. By that, I do not mean those issues engendered by the attitude of residents who trained twenty years ago, but rather those experienced through the eyes, thoughts, and feelings of the present-day surgical resident. These are individuals who are willing to put in long hours--indeed, years--if in return they can experience the satisfaction generated by a high-content curriculum and a more humane lifestyle. If in our wisdom we can effect changes to those ends, we will afford our graduates their best chance to participate fully as leaders in the surgical world of tomorrow.*
*Author's note: There are, certainly, other important areas within our specialty that would lend themselves to clearer analysis through a consideration of attitudinal differences. Rather than address these myself in this setting, I would ask readers to point out their pet projects that could be promoted or peeves that could be changed by altering our attitudes. Also, I am, of course, interested in hearing from you about how you think I may have got it wrong. Thanks. BRW