| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1996;61:511-512
© 1996 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, Texas
Training residents is a nebulous topic, which always produces profuse pontification. This will be no exception. First, this is not just my training program, it is ours—Fred Grover spent 19 years in San Antonio working with me until he finally said that he could not stand my bad jokes and country and western music any longer and returned to Denver. More recently John Calhoon, alias John Boy, has succeeded me as Chief of the Division and Head of the Training Program and has brought it to new heights.
When you ask a program director the best way to train residents, you will find some variant of the same answer: ``There is my way and the wrong way.'' Before discussing my way, I would like to mention the two extremes of the wrong way: (1) ``This would be a great residency program if we did not have all these residents around getting in the way.'' (2) The other extreme is ``How can we run a service if they cut our resident allocation again?'' The first view is that the residents are a necessary evil to be tolerated, and the second is that they are a necessary evil to work for the greater good of doing more operations and making more money. In each case, we throw them a daily rice ration for holding retractors and after two years stamp a sign on their forehead that says ``I am a Thoracic Surgeon'' even if they are so mediocre that we would not even let them operate on our mothers-in-law. Next we send them to the American Board of Thoracic Surgery hoping they will fail the examination and asking the Board to do what we should have done 2 years earlier.
My Way
First of all, it seems trite to mention it, but the only real reason for having a residency training program is that you want to train residents! If you cannot get your jollies out of their accomplishments rather than your own, you should get out of the business of training residents and just hire physician's assistants and nurse practitioners. It is cheaper and easier, you do not have to help them do cases, and you do not have to fill out all those forms! Some of our current pseudotraining programs need to choose this option.
The second problem relates to time. Two years is not enough to master all the knowledge and techniques of our specialty. It is a paradox that, as the volume of skills to be learned increases, we have compressed the time in years and hours per week devoted to mastering it. This is like putting 10 lb of manure in a 5 lb sack and each year we get more manure and a smaller sack. Unfortunately, 7 years is about the maximum we can expect people to remain in training. The only answer to this conflict is to fit more Thoracic Surgery training into the 5 years devoted to General Surgery. The American Board of Surgery requires that no more than 12 months be spent in any one specialty during 5 years of General Surgery training. Other specialties have gone to 1 or 2 years, or in the case of Plastic Surgery, 3 years of General Surgery, before taking some 3 or 4 more years of specialty training. The problem is that these residents do not get the broad base of general surgery experience, and particularly the most valuable part of all, the chief resident year, where operative volume and decision-making are paramount. Disease and injury do not always respect our arbitrary specialty bounderies. Currently the American Board of Thoracic Surgery and the American Board of Surgery are trying to get together to establish an early decision on a ``Thoracic Surgery Track'' so that residents may spend the entire third or fourth year in Thoracic Surgery. Actually we have already done this since the inception of our training program. Our future residents all get 2 or 3 months of Thoracic Surgery per year so that they accumulate more than 12 months during the 5 years of General Surgery. Some of these rotations are called vascular, research, critical care, or transplantation so that they do not raise red flags with the American Board of Surgery. Therefore, what we really do is to approach the problem in a sincere, straightforward fashion, and lie—for altruistic reasons, of course! But at least the residents have an extensive experience before starting 2 years of Thoracic Surgery residency so that they can hit the ground with their feet running.
Our training program began 24 years ago when I arrived in San Antonio. We have trained one resident per year since its inception, and the past 2 years we have taken a second resident every other year. We have the University Hospital and the Veterans Affairs Hospital, which differ in patient and disease population. The University Hospital has an extensive experience in trauma, pediatric thoracic surgery, and transplantation, whereas the Veterans Affairs Hospital has an excess of coronary artery disease and lung cancer. Our residents do approximately 80% of the major operations with active staff supervision. We do not merely give them a book, a knife, and a patient and call it a training program. Each of our residents in recent years has finished with more than 400 major cases as surgeon, and all of them have passed both parts of the American Board of Thoracic Surgery examination. I can proudly say that we have never trained a resident who cannot operate. Our philosophy is that surgery is like sex—it is a lot of fun but it is a lousy spectator sport. Therefore, we let them operate with supervision, which makes the difference between doing 100 pulmonary resections and the same resection 100 times.
Finally, the key to any training program is to attract the best and the brightest. Good people compensate for many inadequacies. Once the tradition of the best and the brightest going into Thoracic Surgery in your institution is established, it is self sustaining and recruiting good people becomes easy. Each year, two or more of our six General Surgery chief residents, and some years as many as five of the six, have decided on a career in Thoracic Surgery. Obviously, we cannot accommodate everyone. In the first postgraduate year, I tell them up front that everybody who works hard and does a good job will be taken care of, if not here, then elsewhere. Many of you have received personal letters from me explaining my problem of having three good residents and one job and perjuring myself while extolling their virtues. So far we have been able to place everyone who deserves being placed. I have always been honest in these letters because credibility is important not only for me but for future generations of residents as yet unborn. Credibility is like virginity—once you lose it, it is gone forever.
The final question is how do you attract the best and the brightest and start that tradition of excellence? I think the best way to point this out is to give you an example that occurred many years ago when I was at another university and getting ready to move to San Antonio. There were a number of residents in the program who had worked in my laboratory as medical students and started a career in surgery with an ultimate goal of Thoracic Surgery as a result of that experience. Before I left for San Antonio, seven interns and residents announced that they were moving with me. They were the cream of the crop! Needless to say, I began to feel about as popular as an illegitimate son at a family reunion. One day the Dean and a couple of senior faculty members and I were having lunch and they started discussing how I had lured all of these bright young people to move to San Antonio. After a while the conversation got a bit unpleasant, and I pointed out to them the secret: first, you have to give a damn about the people who work for you, and second, you have to show it! Once you establish those two principles, everything else falls into place. Perhaps the only thing more important than that is to have a first-class colleague like Fred Grover to help you, but not everyone can be that fortunate. Thank you for listening to me pontificate about my way of training residents!
Footnotes
Presented at the Forty-Second Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 9–11, 1995.
Address reprint requests to Dr Trinkle, Division of Cardiothoracic Surgery, University of Texas Health Science Center, 7703 Floyd Curl Dr, San Antonio, TX 78384-7841.
This article has been cited by other articles:
|
|
 |
|
  W. H. Merrill The Kent Trinkle Education Lecture. He knows that instruction carries less weight when the teacher does not love his students. Ann. Thorac. Surg., June 1, 2008; 85(6): 1847 - 1849. [Full Text] [PDF]
|
|
|
|
|
|
F. A. Crawford Jr Thoracic surgery education Ann. Thorac. Surg., February 1, 2000; 69(2): 330 - 333. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
