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Letter to a Young General Thoracic Surgeon

Tuesday, August 14, 2007

Dear Matt,

I’m not that old, you understand, but something put me in a reflective mood as I thought about you beginning your new practice.  I have, in fact, toiled in the vineyards for twenty-some years and have experienced academic, private practice, and large clinic settings.  So here goes.

  1. This is a great time to be a General Thoracic Surgeon!  Those of my vintage had more offers, and more lucrative offers, to be Cardiac Surgeons; but times have changed.  While Cardiac Surgeons must reinvent themselves, we already have (see below).  People are still smoking, the population is aging, lung and esophageal cancer increase in incidence with increasing age (and adenocarcinoma is increasing anyway), more CT scans lead to more discovered lung nodules, and young career people for some reason hate sopping wet palms.  Chest anatomy is so fine that most surgeons would become General Thoracic Surgeons if they didn’t have to do all that cardiac time.  There are exciting developments in minimally invasive techniques, robotics, multidisciplinary oncology care, and more.  And who has a better reason for social activism (smoking), given what we see every day; your community will embrace you.
  2. You are already a Minimally Invasive Surgeon.  I started performing video-assisted thoracic surgery  (VATS) in 1992 and I was far from the first.  The chest is better than the abdomen for this type of surgery, since one need not maintain that pesky air-tight seal and the alternative, spreading the ribs, really hurts.  VATS lobectomy is already a great operation and techniques and tools will only get better.  Don’t be afraid to be a pioneer.
  3. You are already a Surgical Oncologist.  Fortunately or unfortunately, much of what we do is oncology; it just happens to be specialized to the chest.  In some hospitals and communities you would be the only Surgical Oncologist; some Cancer Centers are specifically recruiting General Thoracic Surgeons as Directors.  Embrace your cancer-fighting skills and, for that matter, your Medical and Radiation Oncology colleagues: being cognitive specialists, they are bright enough to value your input and some even tolerate surgeon friends.   Attend Tumor Board religiously; if there is no Thoracic Oncology Conference start one.
  4. Your mantra must always be "service to patients." Your practice will thrive if you do nothing but keep this foremost.  And it’s the right thing to do.
  5. Constantly educate.  Every chance I get I suggest to primary care doctors, Oncologists, and Pulmonologists that General Thoracic Surgeons should be their first call for patients with these three problems: a. large unilateral pleural effusion (whether neoplastic or infectious we can promptly diagnose and deal with it); b. mediastinal adenopathy; and c. solitary pulmonary nodule or mass (we can follow, diagnose, assess candidacy for resection if indicated, treat appropriately).  Of course, there are many other reasons to call us, but they know most of those.
  6. Palliation is a reasonable, even noble, goal.  We can’t cure every patient, but we can make most feel better.  We see a minority of chest cancer patients for curative resection, but we can help many more.  Educate your colleagues about your skills in caring for malignant effusions, tracheobronchial obstruction, and dysphagia.  Be sure that they know that no case is too small and no problem too difficult.  Much palliation can be done under local anesthesia and sedation.
  7. Keep up-to-date.  This requires a mind-set, an openness to change.  A former partner of mine, for example, had performed open cholecystectomies for 30 years but learned laparoscopic cholecystectomy several months before his known retirement date.  Look what vascular surgeons must learn to do with catheters and fluoroscopes.  VATS lobectomy should be the standard operation for many lung cancers.  If we don’t do radiofrequency ablation of selected cancers in the lung then we will be bypassed and some patients will be denied the opportunity for resection.  Endobronchial ultrasound can’t be that hard to learn, can it?  Who knows what will be next?
  8. Mentors.  Actively seek mentors and plan to be one some day.
  9. Join the club.  Participate in trials and the STS database.  Join the General Thoracic Surgical Club, STS, AATS, ACS, local chapter of ACS, and others.  General Thoracic Surgeons are an affable group, especially around an open bottle (damn, my third wine allusion).

This is beginning to sound like a bad presidential address, so I will stop.  Besides, I have a case to do and that chest anatomy is so fine.


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