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It comes as no surprise to anyone that significant forces have played a role in changing our practice of Thoracic Surgery. Reimbursement issues, decreasing referrals for coronary bypass, and decreasing interest in Thoracic Surgery as a career option for medical students have negatively impacted the health of our profession. The answers to these problems are multifactorial and no doubt will be addressed as our profession shifts gears and prepares for the next 20-30 years.
One of the issues that has been raised over and over again is the decreasing interest of medical students in opting for a career in Thoracic Surgery. Many reasons are noted to explain this trend, such as the long training period, the perceived unfriendly culture towards women (women now comprise 50% of the medical school class), decreasing reimbursement, and the lack of access to role models during their formative years in medical school. Because of curriculum restructuring, less time is spent on surgical services and therefore students are not exposed to role models early in their careers.
One answer to this particular concern is a greater awareness of and increased participation in the medical school curriculum. Thoracic surgeons need to have access to the decision-making core of the medical school in order to expose medical students to subspecialties that have been selected out of the experience. Thoracic surgeons need to aspire to leadership roles within the medical school to make policy and impart to their colleagues the importance of exposing medical students to the various subspecialties, whatever they may be.
There are several models by which thoracic surgeons exert influence on the medical school structure. The most common is the Division Head position within the Department of Surgery. Under these circumstances, the Chairman, usually a general surgeon, has control of the surgical curriculum and sits on the various committees of general medical education. In some medical schools, the Division Head of Thoracic Surgery has been elevated to the Chair of the Department of Thoracic Surgery within the medical school. Under these circumstances, he/she could have more influence on the curriculum. Still another model is for the Thoracic Surgeon to be Chairman of the Department of Surgery. Under these circumstances, the potential for two leadership positions in thoracic surgery (the Chairman and the Division Head) can serve the process.
The same is true in pediatric hospitals. Traditionally, the Surgeon-in-Chief leads a pediatric surgery department within the limits of the pediatric hospital. This individual serves as the local chairman of the department and oftentimes serves as a Vice Chairman within the Department of Surgery of the medical school. Under these circumstances the pediatric surgery faculty usually has dual appointments: within the department of pediatric surgery at the pediatric hospital and within the particular surgical department of the medical school. The pediatric cardiac surgeon under these circumstances is the Division Head of Pediatric Cardiac Surgery within the pediatric hospital and a member of the Division of Thoracic Surgery within the medical school. Because of their very specialized practice, pediatric cardiac surgeons rarely have an opportunity to serve in leadership roles within the medical school. The pediatric hospital may be geographically remote from the adult hospital making governance of both parts of the division difficult (the larger cardiothoracic units: adult cardiac and general thoracic surgery are within the adult hospital). As a result, Division Heads of Thoracic Surgery within the medical school tend to be adult cardiac or general thoracic surgeons.
In the case of separate pediatric hospitals, the natural ascent to a leadership position for a pediatric cardiac surgeon is the position of Surgeon-in-Chief or Chairman of a Department of Pediatric Surgery within the medical school. The Surgeon-in-Chief of the pediatric hospital has many duties in which he/she can impart considerable mentoring of medical students and younger residents who are not yet committed to a specialized career in surgery. In some medical schools, a Department of Pediatric Surgery has been created thereby increasing the influence of pediatric surgery by a direct reporting structure to the Dean of the medical school. This, of course, has many advantages for the entire specialty structure of all the components of pediatric surgery (orthopedics, urology, otolaryngology, plastics, general, and neurosurgery, among others). Research space, philanthropy funds, and access to administrative resources can all enhance the Department of Pediatric Surgery. Pediatric cardiac surgeons should engage in the structure of the pediatric hospital and the medical school by committee service, medical student lectures, and other extracurricular activities. When the opportunities present themselves, pediatric cardiac surgeons should make themselves available for these administrative positions, imparting their leadership skills and notable attributes to inspire the next generation of surgeons.