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The Case for Standardized Global Education, Training and Certification in Cardiothoracic Surgery

Saturday, November 8, 2003

My interest in developing the case for a standardized global education, training and certification course of action results from my involvement in some of the organizational activities that relate to the educational, training and certification process in the United States and to my involvement with CTSNet. I have watched with admiration the efforts of CT surgeons around the world who use their skills for the benefit of patients in lesser developed countries, spending their time and money in these volunteer missions in a purely humanitarian endeavor. While there are no downsides to anything that helps sick people, the end result of temporary visits by a CT team is that the team packs up and goes home, and the site of the mission reverts to its previous state only to wait until another visit. Furthermore, more and more surgeons from underdeveloped countries are returning home to bring new medical technology to their homeland, and many of these are well trained and highly motivated surgeons. They uniformly find few resources available to them, although many have become very proficient at successfully adapting to the resources available.

One element to the lack of resources for these surgeons is that most, if not all, of the patients that they are treating have no money to pay for their care. Abject poverty is not uniformly the case in any country; there are always some people who can pay for their medical care. However these potential patients often seek special medical care in other, more developed, countries because they are of the firm opinion that they will receive better treatment. This prospective source of revenue for the surgical program in the home country is thus not available, and a vicious cycle is initiated. The low regard that the local surgeon enjoys is not justified, but the lack of a recognizable certificate of competence sometimes precludes appreciation of their merits. In addition if the local team were part of an international database, so that the good results of their work could be widely assessed, many more affluent patients would stay at home.

My thought is to develop a uniform, widely recognized system that will enable patients throughout the world to evaluate the surgeon and the team, and to compare groups in various countries and within countries so that an evaluation will have meaning. This is not a proposal to have a beauty contest, as is so widely publicized in the US, simply ranking surgeons on their mortality statistics. This is a fallacious idea, and has little to recommend it. At the moment, in the US, I believe the best way for the public to evaluate their surgeon is to have some notion of what their training and experience has been. This is not perfect, but at present it is the preferable method.

This works in the US because we have a fairly standardized, defined curriculum that is incorporated into a program of education, training and, finally, certification in our specialty. It is beyond the scope of this short piece to describe the process fully, but I can give an outline. The origin of the process for specialty certification began in 1946 when a thoughtful group of foresighted thoracic surgeons serving on a committee of the American Association of Thoracic Surgery recommended that a Board of Thoracic Surgery be formed in affiliation with the American Board of Surgery. At the meeting of the AATS in St. Louis in 1947 the committee's report was accepted and the first organizational meeting was held in 1948. In 1971 The Board of Thoracic Surgery became an independent board, no longer being a sub-board of the American Board of General Surgery.

There are three relatively independent but interrelated elements to the certification process. The Thoracic Surgery Directors Association, made up of the directors of the 95 odd CT training programs in the US, is responsible for implementing the curriculum and monitoring the performance of the resident's clinical skills. The Residency Review Committee is charged with examining the quality of the training programs, using guidelines promulgated by the RRC as well as the Accreditation Committee on Graduate Medical Education, being certain that the training program meets the standards of the specialty. Finally, the American Board of Thoracic Surgery is responsible for examining those residents who have satisfactorily completed the training program (attested to by the Program Director). Only those candidates who have successfully completed an approved Residency Program are eligible for examination for certification.

The explanation as to why this scheme is so widely accepted is the integrity of the entire process. First, it is implemented and run by working surgeons, not by government bureaucrats. Second, the process is scrupulously honest; having served on the Residency Review Committee for 5 years, I am witness to the fact that there is strict attention to the facts, unbiased by friendships or any political affiliation. This is essential if there is going to be general acceptance of the value of Board Certification.

Until this time, the logistics for developing a world-wide process like the one I have described were overwhelming difficult. However, in the last few years, the growth and wide acceptance of CTSNet around the world has indicated that a global CT surgery community now exists. The implementation of a global education, training and certification program is a possibility because most of the material can be shared and the process developed using CTSNet. For example, at the present the in-service examination for the residents in training is done using CTSNet, and has successfully implemented for the past two years. The residents report their operative experience directly to the American Board of Thoracic Surgery using CTSNet. The European Board of Thoracic Surgery has just developed an operative log on CTSNet so that the European trainees can record their operative experience directly on-line.

This new initiative will not be a replica of the American Board of Thoracic Surgery or the European Board of Thoracic Surgery. This new organization will need to have its own set of guidelines and objectives. There is no reason that we cannot build on the experience of the American Board or the European Board; it would be foolish to start from the beginning. Different cultures and local customs will require compromises, but the end-product should be the same, well-trained, ethical and competent CT surgeons. The public should know that their surgeon is qualified if the surgeon meets the standards of the international community.

Most of the curriculum for CT surgery is available on CTSNet, or can be placed on it without much difficulty. Dr Peter Greene, the genius who is most responsible for the creation of CTSNet, has been working with IBM and Sun Microsystems to develop a standardized XML language that will permit total uncomplicated interactivity between all Internet sites, and this will be a huge advance. Moreover, his group is in the final stages of implementing a fabulous program that will permit the use of educational material in packets from multiple sources, which will reduce the duplication that is so time consuming and expensive at present.

The necessary framework is in place to accomplish this enormous task. Like so many tasks, the hurdles remain, largely political and logistical. The world is big complex place; there will be language problems, financial problems, ego problems, and differences in style and strategy. However, it can be done. If we can gather up enough dedicated colleagues, who have foresight and determination, we can achieve this monumental goal. It will be good for patients, for medicine in general and for our specialty.

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