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Ann Thorac Surg 1995;60:236-238
© 1995 The Society of Thoracic Surgeons
Department of Surgery, McGill University, Montreal, Quebec, and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
Richard Peters' landmark editorial [1] about the deterioration of cardiothoracic surgical education, and the inappropriateness of using 5 years of general surgery as a filter to select candidates for a brief 2-year period of training encompassing both cardiac and general thoracic surgery, was a cri du coeur that provoked an outpouring of thoughtful responses [2–5]. The accompanying Editorial Symposium [6–10] and two retreats sponsored by the leadership of North American cardiothoracic surgery [11, 12] documented a high level of commitment to reexamine our assumptions about residency education.
Peters stressed that a complete reevaluation of the educational sequence for cardiac and thoracic surgery was needed. He drew attention to the increasing paperwork, secretarial, and messenger duties and disjointed clinical experience continually interrupted by unnecessary pages that has replaced the surgery residency of 30 years ago. Senior cardiothoracic surgeons in decision-making positions were described as inclined to preserve the status quo ante, based on recollections of their own experience of a residency ``nostalgically preserved in clouded memories.'' Third and fourth generation cardiothoracic program directors were challenged to develop a ``force to overcome the built-in inertia to change.''
Despite prolonged training, many graduates of cardiothoracic residencies were underprepared to practice as consultant specialists. Many sought further training after completion of residency to gain needed experience in specialized areas such as congenital heart surgery or lung transplantation, or simply to strengthen and mature their skills in the more common operations of the specialty. Although cardiac surgery training in most programs in the United States was generally thorough, few surgeons performing general thoracic operations had more than 6 months of dedicated training in general thoracic surgery regardless of their certification [8]. How many leaders in cardiothoracic surgery would accept a kidney or prostate operation from a specialist with 6 months or less of specific training on a dedicated urology service?
In contrast, general thoracic surgery developed in Canada as a more clearly defined, specialized area of surgery. The Certificate of Competence in General Thoracic Surgery, originated by Pearson in 1976, required 6 months of junior residency in general thoracic surgery on a dedicated or mixed service, 6 months of cardiac surgery, and 12 months as senior resident on a general thoracic surgery service. The development of this program raised the practice of general thoracic surgery to a consultant level even when practiced in combination with general surgery in the community. The duration of required training was 6 years including 4 years of general surgery. Certificants who added thoracic laboratory experience were well prepared for careers as academic general thoracic surgical leaders. The intrinsic merit of Pearson's educational initiative was recognized throughout the world. Dedicated general thoracic surgery services have developed slowly in the United States, closely affiliated with and sometimes submerged in predominantly cardiac surgery programs of training. Resident education in general thoracic surgery continues to be relegated to faculty whose primary interest is in cardiac surgery in many programs [8].
A mandated increase in length of general surgery training in Canada to 5 years, a confusing array of pathways to general thoracic surgery certification via cardiothoracic as well as general thoracic residencies, and loss of access to the American Board of Thoracic Surgery certification process prepared Canadian surgeons to respond to Peters' challenge with action. A Task Force was charged by the Canadian Association of Cardiovascular and Thoracic Surgeons and the Royal College of Physicians and Surgeons of Canada to reassess graduate education in cardiac and general thoracic surgery. A principal goal of the Task Force was to shorten the overall length of training and eliminate the ambiguity in general thoracic credentialing. Opinions were sought from all members of the Association, from Canadian university surgical chairmen, and from the appropriate Royal College committees. The background and the process of evaluation and approval are presented in more detail elsewhere [13]. Some surgeons on the Task Force, basing their views on strongly held belief in their own educational experience, argued for intensifying efforts to mimic the cardiothoracic model required in the United States. The inertial force of traditional thinking almost overwhelmed the impetus for change. The committee considered a cardiothoracic model with tracks emphasizing either general thoracic or cardiac surgery, under a joint oversight committee comprising equal numbers of cardiac and general thoracic representatives. Another view proposed separate oversight committees and programs of cardiac and general thoracic surgery that were federated only at the University level to coordinate the educational needs of each stream of residents.
Aldo Castaneda's Presidential Address to The American Association for Thoracic Surgery [14], delivered immediately before our final committee meeting in New York City in April 1994, provided a critical stimulus. Within hours of his passionate and articulate charge to reduce unproductive time in training, the Task Force formulated an abbreviated but enriched program. The Royal College of Physicians and Surgeons recognized the merits of this proposal. The Council of the Royal College clearly separated responsibility for governance by designating two autonomous supervisory bodies. After an accelerated review process, the Council approved separate, primary specialty status for cardiac and general thoracic surgery in September 1994.
The newly defined pathways will allow residents to become masters of their selected clinical specialty at a relatively young age. The year of academic enrichment included within the 6-year program allows access to the recently approved Clinician Investigator program of the Royal College of Physicians and Surgeons, which will bring residents to the equivalent of a doctoral level of scholarship by adding 2 or 3 additional years of study at the branch point of their year of academic enrichment. This provides a logical model for the education of the future teachers and academic leaders in thoracic and cardiac surgery, as emphasized by Pories and Aslakson [15].
Under the new program, specialists will have a rich experience during a 6-year residency in cardiac or thoracic surgery, which includes graded responsibility and the collegiality of an extended peer group. Their prerequisite education begins with 2 years of core training in surgery. The 24-month core period is individualized to meet the educational needs of the future specialist by the selection of electives in appropriate surgical or medical rotations, in addition to the mandatory rotations in general surgery, emergency medicine, and surgical intensive care, selected surgical specialty rotations, and a 24-month seminar series in the Principles of Surgery. The core training period is coordinated by the core faculty committee, comprising surgeons representing the participating surgical specialties, and chaired by one of them, who may not be a general surgery specialist. The overall direction of the resident, including selection of electives during the 6 months allotted for this purpose, is the responsibility of the surgical specialty program director, eg, in cardiac or general thoracic surgery.
During the third and fourth years, residents in both streams spend 6 months as junior residents in general thoracic surgery and 6 months as junior residents in cardiac surgery. Thoracic stream residents pursue a 12-month senior rotation in general surgery, which might include emphasis on cervical or oncologic surgery. Cardiac stream residents perform 6 months of senior general surgery residency and 6 months of pediatric cardiac surgery. The year of academic enrichment may be taken at any suitable place in the educational sequence as determined by the program director and the resident, but is listed as the fifth year in Tables 1 and 2
for clarity. All 6 years of training are supervised by the program director in general thoracic or cardiac surgery, collaborating with the core program director and the general surgery program director. This will allow effective implementation of a defined and coordinated curriculum for all years of training.
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It is possible to achieve double certification by fulfilling the requirements for each specialty. Surgeons preparing for a community practice of general surgery combined with general thoracic surgery will require 18 to 24 months of additional training after completing general surgery to attain both certificates. Surgeons planning a combined practice of cardiac and general thoracic surgery will have a similar increase in their training of 18 to 24 months to qualify for certification in both specialties.
The success of this initiative will require cardiac and thoracic surgeons to strengthen their skills and participate more actively in undergraduate medical education to attract and guide appropriate candidates to the specialties. Our increased responsibility for the 6-year training period will require a well-organized educational plan for the resident and the faculty. A structured, graded curriculum specifying the knowledge, skills, and attitudes to be gained at each level should be developed based on the outstanding work of the Thoracic Surgery Directors Association [17].
This response to Dr Peters' challenge was not developed easily, and the ultimate result is not yet tested. We intend to follow the careers of our graduates carefully, to assess the impact and effectiveness of these decisive steps taken to restructure the sequence of education. The specialties of Cardiac and Thoracic Surgery in Canada can approach the horizon of the 21st century with confidence and pride in a revitalized and flexible educational process focused on the needs of our students.
Footnotes
Address reprint requests to Dr McKneally, Division of Thoracic Surgery, The Toronto Hospital, Eaton North, 10-230, 200 Elizabeth St, Toronto, ON, Canada M5G 2C4.
References
This article has been cited by other articles:
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  J. P. Gold, W. B. Begg, D. A. Fullerton, D. J. Mathisen, M. B. Orringer, and E. D. Verrier Evaluation of Web-Based Learning Tools: Lessons Learned from the Thoracic Surgery Directors Association Curriculum Project Three-Year Experience Ann. Thorac. Surg., September 1, 2005; 80(3): 802 - 810. [Abstract] [Full Text] [PDF]
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J. P. Gold, E. A. Verrier, G. N. Olinger, and M. B. Orringer Development of a CD-ROM internet hybrid: a new thoracic surgery curriculum Ann. Thorac. Surg., November 1, 2002; 74(5): 1741 - 1746. [Full Text] [PDF]
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R. J. F. Baskett, K. J. Buth, J.-F. Legare, A. Hassan, C. H. Friesen, G. M. Hirsch, D. B. Ross, and J. A. Sullivan Is it safe to train residents to perform cardiac surgery? Ann. Thorac. Surg., October 1, 2002; 74(4): 1043 - 1049. [Abstract] [Full Text] [PDF]
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