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Ann Thorac Surg 1997;63:309-311
© 1997 The Society of Thoracic Surgeons
Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
It is extraordinarily risky to contemplate the future of thoracic surgical training in these rapidly changing times. It is hard to even imagine what thoracic surgeons will be doing in the future, particularly based on the huge changes in technology and reimbursement that have occurred. However, it is certainly enjoyable to predict the future, particularly if one is not held accountable. The views that are stated in this article are purely my own and do not represent the Thoracic Surgery Directors' Association or even the Curriculum Implementation Task Force, which I chair.
I have been extremely fortunate to have had my thoracic surgical education at the University of Virginia and have recently had the opportunity to head this program. The program was founded by Dr William H. Muller, Jr, our former Professor of Surgery and, obviously, one of the great names in thoracic surgery. Doctor Muller brought the training scheme from Johns Hopkins, where he was one of Alfred Blalock's residents. Doctor Stanton P. Nolan took over the program from Dr Muller and continued to develop an excellent training program. The training program is essentially an apprentice system, which most of us use to this day. The apprentice system is not so bad, and I believe many of us have put out excellent residents. At the University of Virginia there has been an emphasis on allowing the residents freedom to perform a large number of operations and to look after their own patients. This was done without them having to do much of the scut-type work that may occur in more poorly organized hospitals. We are also fortunate to have maintained a large case volume and a large variety of procedures to perform. It is interesting that we have not significantly changed the style of our program since Dr Muller started it. There is maybe a little more organization of the rotations, but otherwise the concept is the same. I believe this is true for most of us in thoracic surgical education. If one looks at how often thoracic surgical education is examined in the literature, one will find that this almost never occurs. In the last year there was one citation in Index Medicus related to thoracic surgical education. The year before that there were three. In the same time frame there were 97 citations relating to cardioplegia or myocardial protection and 38 citations for thoracoscopy. I would suggest that the variations on the myocardial protection theme have far less to do with the overall good for mankind than the few articles on thoracic surgical education. Our future is in the residents whom we educate. Despite this, I believe we put out a good product. Yet, to quote Mark Orringer, "It is easy to make a silk purse out of a silk purse." The discussion in the rest of this submission will relate to three basic subjects: (1) should one reduce the operative caseload for the residents to allow them more reading time; (2) is the American Board of Surgery certification necessary or helpful; and (3) should our programs be changed to a curriculum-based program from the apprentice style, and how can this curriculum be implemented?
One of the hypotheses of the Oak Brook Conference, which took place in 1992, was that potentially the residents were spending too much time in the operating room and, if they had more time to read, they would fare better. It was noted that the residents do 400 cases total based on those residents graduating programs between 1988 and 1992. The makeup of the caseload was 33% general thoracic and the rest related to cardiac [1]. It has been suggested by some very good people that we should definitely allow the residents more time to read and learn and spend less time in the operating room. There are very few data either way regarding this viewpoint.
I have unofficially polled our own residents and those who have applied to our program for a residency. The residents themselves do not want to spend less time in the operating room or in clinical patient care. Obviously, they need to learn how to be surgeons by learning how to operate and taking care of patients. It seems appropriate that they do not do repetitive operations like multiple coronary bypass grafts. They certainly should not be pulled from general thoracic surgical cases or endoscopies merely to do another coronary artery bypass graft. However, it is unlikely that giving them a little time to read on the side will improve them significantly. I learned an interesting thing upon polling these residents. The reason that they spend less time reading thoracic surgery in their first year of thoracic surgical training relates to having to take the American Board of Surgery examination. This, basically, is a 1-year phenomenon in that they have to prepare first for the written examination in the fall and, if they are successful at passing this, then they must take the oral examination in the spring. In the meantime, they have spent the first year of a 2- or 3-year program reading general surgery. Therefore, I would suggest that reducing their time in the operating room may not be the issue. It would be important to work with the American Board of Surgery to make certain that they can get through the American Board of Surgery certification in 6 months or less and spend the rest of the time in their programs learning thoracic surgery.
This clearly brings us to the next major issue: is American Board of Surgery certification necessary? As many of you have heard, the Thoracic Surgical Program Directors had a retreat regarding thoracic surgical education. The Program Directors voted that the American Board of Surgery certification be made optional. There were extremely valid points on both sides of this issue. Those who were against American Board of Surgery certification suggested the following reasons. They thought that the training was too long. This was particularly important in that graduate medical education will not likely be reimbursed after the first residency program. Most of the directors felt that the time required for thoracic surgical training is too short. They suggested at least 3 years be devoted fully to thoracic surgical training to cover the breadth of the field. Most importantly, it was suggested that the general surgical training programs were not teaching the residents what they need as prerequisite education to thoracic surgery.
Those who believed that the American Board of Surgery certification was important had the following viewpoints. Many of this group desired to maintain traditional ties to general surgery as the start for all of the specialties. Most felt that the chief resident year in general surgery was too valuable to give up. It was also wondered whether medical students could reliably choose a thoracic surgical residency before surgical residency. Some doubted whether we really needed 3 years to educate residents in thoracic surgery if the general surgical program could do a better job in the prerequisite curriculum. However, maybe the most valid point raised related to what happens to general thoracic surgery. If cardiothoracic surgery went its own way, would the general surgeons push to have general thoracic surgery become part of their overall specialty? Can general thoracic surgery relate fully to moving away from general surgery in that some of the areas, particularly esophageal surgery, are clearly very much related? I personally favor the latter viewpoints. I think the chief residency year in general surgery is much too valuable to give up. To get the residents after 3 or 4 years of general surgery means that we are getting the individuals who have maybe the weakest rotations before coming to thoracic surgery. I believe our focus should be on improving the prerequisite curriculum. We should work with the American Board of Surgery to allow the residents who are going into thoracic surgery to have a more focused view on thoracic surgery during their general surgical residency. This mechanism already is in place. If we are truly to get away from general surgery, it is illogical to give up the best year of all, which is the chief residency year. If that should occur, we would be better off, I believe, selecting the thoracic surgical residents as interns and designing their whole training program from the beginning as the neurosurgeons do. However, we do not really know the right answer to all of this, and it may be that experimental programs should be designed to study this more closely. My opinion related to this is not alone. I have polled the Southern Thoracic Surgical Association membership about what they preferred in new partners. It seemed to me that this would be the best way to figure out what type of product we should put out. The poll basically asked the preference regarding American Board of Surgery certification or the length of the thoracic surgical training program for potential new partners. The total response was extraordinary. Forty percent of the Southern Thoracic Surgical Association responded. They really did not care whether their new partners came from 2- versus the 3-year program (Table 1
). However, they overwhelmingly felt that the American Board of Surgery certification should be maintained (Table 2).
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During the organization and work on the Curriculum Implementation Task Force, we began to learn what resources have been available to us. Clearly, the technology is extraordinary. Some of the things that can be used to improve our teaching of the curriculum are areas such as surgical skills laboratories. We assume that the residents coming into our programs know how to tie knots and suture based on their time in general surgery. Many of us feel this is not necessarily true. Although virtual reality probably is not at a level at this point to help develop the surgical skills for thoracic surgery, it may become useful in the future. CD-ROM technology presently is a way to go. It can be used as a source of information and as an interactive tool. A curriculum can also be tied to a Web site related to the Thoracic Surgical Directors Association. The Society of Thoracic Surgeons has already developed a Web site due to the work of Dr Replogle, and certainly we have the ability to use the Internet to quickly spread information. We also must develop a prerequisite curriculum to at least let the General Surgery Program Directors know what our residents need to be taught if we maintain American Board of Surgery certification. Program Directors and the attending surgeons of the thoracic surgical residencies must learn education skills and learn how to be teachers.
Despite the rapid changes in technology and reimbursement, we live in exciting times. I would suggest that we will do a lot more for mankind in general and our patients specifically if we improve the education of our residents. It is not likely we have the tools to test the results of these changes. We are presently able to attract the best and the brightest of medical students and, in fact, most are doing an excellent job after they finish their residencies. However, improvements in curriculum will allow the residents to enjoy their time better and more quickly and simply assimilate the knowledge. Those programs that make those changes are likely to continue to attract better residents than those who do not. This may be the major reward that we get.
Footnotes
Presented at the Forty-third Annual Meeting of the Southern Thoracic Surgical Association, Cancun, Mexico, Nov 7–9, 1996.
Address reprint requests to Dr Kron, Department of Surgery, University of Virginia Medical Center, Box 310, Charlottesville, VA 22908.
References
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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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