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Thursday, February 5, 2009

The field of cardiothoracic surgery is undergoing a transition. Arguably, the entire field of medicine is undergoing an even more significant one. The majority of young medical students are choosing their lifetime professions based on the potential for integrating their professions with an enjoyable and fulfilling lifestyle. This represents a paradigm shift. In the past, the profession itself guided the decision; the lifestyle was to be molded secondarily. I completed my surgical training in an era when it was an expectation that one would sacrifice one’s family for the profession. It demonstrated commitment and dedication. To some, it was a point of honor.

Young medical students want a professional career where they can experience the excitement of effectively confronting new issues in patient care, but where they can do these things, and go home. They have challenged the dogma of the necessity of personal lifestyle sacrifice for the profession and, in doing so, have challenged us. I propose that we must not shrink from this challenge, but must, as have so many other fields, meet it. We must recognize that it is has been the type of spirit that has fueled the challenge of the status quo that has resulted in the advancement of many things in medical culture, if not civilization.

I am a pediatric cardiac surgeon in a busy pediatric cardiothoracic program. I am fortunate enough to work in a field that captured my dreams from my earliest years in medical school. I work with a wonderful team of people in a field that is continuously changing…where I learn something new every day, and where every week I see something that I would have previously thought impossible. I have a loving and supportive husband, and we have a daughter who is unquestionably the greatest joy of our lives. My husband and I run a laboratory together, having decided to consolidate our efforts after the many moves over the last several years. We have the opportunity to experience the empowerment that comes from seeing a clinical problem that needs to be addressed and having the resources to address the problem together.

It has not been an easy road. I trained for fifteen years in some of the most challenging programs in the United States. I went through a pregnancy while on call in the hospital every other to every third night. I wanted to become a pediatric cardiac surgeon. I also wanted to obtain the training to be able to study unanswered questions that affected patient care. My vision for my future career was not in keeping with the traditional expectations for professional development. Though originally part of the vision upon which the field was based, such a vision was vanishing before my eyes. My determined pursuit of what has become an unconventional goal was not without its consequences. There were times when the difficulties posed made the appeal of the profession difficult to ascertain. There were other times, however, when my desire to care for children with congenital heart disease was so strong that all difficulties seemed surmountable.

Those of us who trained in the era of unrestricted work hours know well how to work long hours, make sacrifices, and deny ourselves simple pleasures. We were well schooled in the culture of our trade. Much of our training came from being there for all aspects of a patient’s course; from seeing the large numbers of outcomes that one sees when in the hospital for long hours. Many of us worry that it will be difficult to produce proficient cardiothoracic surgeons with a shorter training week.

Transitions have to be made.

The skills and judgment necessary to be a proficient cardiothoracic surgeon are of a high level. They are no less today than they have been in any previous time period. We are now charged with designing training that will result in the attainment of these skills in a shorter period of time. There is no longer time for trainees to prove themselves to us in order to obtain the right to be trained. We must assume that if we chose to train these individuals, that if we accepted them into our programs, that they are worthy of our efforts. Just as we expect them to respect us for our knowledge and skill, we must respect them for their decision to choose medicine and to pursue our field. We must use the information technology currently available at our fingertips to make training more efficient. We need those that trained in past eras, those who have sacrificed more than most of the future generation will hopefully ever know, to train the next generation. We need our most experienced surgeons, those who can now teach with ease, those for whom the details of the operations are now second nature, those who can guide trainees through an operation easily, having already seen the myriad of pitfalls that each operation can offer, to teach our youth, without bitterness and with hope. We must ask those who have already given to give even more.

In the year 2009, I think the majority of cardiothoracic surgeons recognize the changes in our field in the last five to ten years. Indeed, most would agree that the luster of the field has faded a bit. This is due to many reasons, but not the least of which is our belated recognition of what is required to move into the future and bring the next generation with us.

I think it is possible to create a happy medium, a middle path, where a cardiothoracic surgeon can have both a fulfilling practice and a rewarding family life. My husband has made sacrifices in order to support my career and our family life. We have worked hard to fashion our careers so that we could meld professional and family life. Twenty years from now, we hope to be able to say that our daughter has been spared the level of sacrifice that some children of cardiac surgeons have known in the past. There have been some growing philosophical changes within cardiac surgery during the last decade. There are now many that are committed to doing those things that would be necessary for the future generation of cardiothoracic surgeons to choose the field of cardiac surgery and find support within the profession to pursue their lives with their families. There are both national efforts (such as those within the organization of the Women in Thoracic Surgery) and local efforts within individual institutions. 

Cardiothoracic surgery in the year 2009 is not the field for someone who is looking for a career in which there are standard, direct, or easy paths to both a happy family life and a fulfilling career. It is not a field in which a woman will necessarily enjoy the same recognition and monetary benefits for the same amount of work or training performed by a man. This is a field where there are many who are working to pave these paths and where there are those who worked even harder to assure that we now have the potential to envision such paths. Even as there are those who still make it difficult for women to excel in the profession, there are others who have risked their careers to aid them in their efforts.

The past president of the AATS, Craig Miller, issued a call to arms in his recent presidential address and throughout the year of his presidency. He called for renewed development of younger surgeons in an attempt to invigorate the profession for decades to come. As a profession, we have a strong heritage in cardiac surgery. We should be proud of this heritage. There are few annals of medicine that are more exciting than the birth of open heart surgery or the developments that led to the first heart transplants. We must preserve this heritage, the only way we can, by finding, attracting and indeed welcoming the same energy, creativity, honor, intelligence, and stamina that resulted in the birth and growth of the field in past decades.

I love the field of cardiothoracic surgery. I love the physiology. I love the feel of working on tiny little blood vessels. I love taking care of small children. And I love being able to participate in a mission that touches my heart deeply, that I can dedicate myself to completely, without reservation. Without question I love these aspects of my work; however, every bit as much, I love and need my family.

It is worthy of mention that mentors from both the old and new schools encouraged me to pursue a family life while pursuing my career. It is also worthy of mention that much of this quest was fueled by the reaction of my junior trainees, who viewed my training lifestyle with horror and chose alternatives. It is likely that these individuals have preserved my ability to contribute to the field, and the grounding that I now have in my personal life has likely preserved my happiness and increased my productivity.

The field of cardiothoracic surgery immerses one in the gamut of the human emotional experience. I may be involved in a case at work and have the gratifying experience of performing a reconstructive procedure from which a child does well. I may also, however, witness a family’s indescribable sadness over the loss of a child who succumbs to the ravages of infection or loses a race against time awaiting an organ transplant, or even worse, dies as a result of a situation that I could have managed differently. When I return home drained and exhausted after a long day or night and am greeted with the beautiful sound of our three year old calling “Mommy” as she happily runs to me with open arms, the flicker of hope, the feel of infinite possibilities returns. I am able to get up the next morning and begin again the work for which I have trained so long, so that the parents of the children I care for will be able to feel the same hope, and the same infinite possibilities.

My intense desire to contribute to the medical care of children is as strong now as it was 18 years ago. Today, however, I hope to make these contributions, and go home. I owe my confidence that both can be accomplished to the cardiothoracic surgeons of the past and to those of the future. It is my privilege to be a pediatric cardiothoracic surgeon and a scientist. I look forward to sharing that privilege with the next generation of pediatric cardiothoracic surgeons that I and my colleagues train for the future.

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