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Ann Thorac Surg 1997;64:596-598
© 1997 The Society of Thoracic Surgeons
Chairman, Major Issues Committee of The Society of Thoracic Surgeons
With the thrust of its rockets ignited by the vision and energy of Robert Replogle, immediate past President of The Society of Thoracic Surgeons, and Thomas Ferguson, Editor of The Annals of Thoracic Surgery, the specialty of thoracic surgery has lifted off toward an unprecedented global electronic sharing of information. The formal establishment of the Cardiothoracic Surgery Network, with technical and editorial support from the Hopkins-based Community of Science, provides the Internet umbrella under which future thoracic surgery communication will reside. Our scientific journals on-line, rosters and demographics of the membership of our thoracic surgery scientific organizations, and current information from the Thoracic Surgery Directors Association, to name but a few, will be readily accessible on their respective Web pages. But as we enter the 21st century with resolve and commitment to harness the energy of this explosion in information technology for the betterment of our patients and our specialty, there is a need for the thoracic surgery community to come to grips with a fairly basic issue about which we have skirted resolution for nearly 30 years: What are we going to call ourselves? How should our specialty and its component subspecialties be designated? The terms thoracic, cardiothoracic, cardiovascular and thoracic, cardiac and thoracic, cardiovascular and general thoracic, heart and chest surgery, and others are now used without consistency throughout the United States and the world. This is more than a nuisance issue. It has very pertinent socioeconomic and professional implications.
How did the current morass of terms applied to thoracic surgery and its component subspecialties evolve? The American Association for Thoracic Surgery was founded in 1917. The Board of Thoracic Surgery was established as an affiliate of the American Board of Surgery in 1948 as a certifying organization for thoracic surgeons. In 1971, it severed its affiliation with the American Board of Surgery and changed its name to the American Board of Thoracic Surgery. The Residency Review Committee for Thoracic Surgery began in 1966 but assumed its tripartite representation from its parent organizations in 1970. The Thoracic Surgery Directors Association was incorporated in 1978. As these credentialing, accrediting, and educational bodies of thoracic surgery emerged, antituberculous chemotherapy virtually eradicated the need for operative intervention for tuberculosis, and the development of cardiopulmonary bypass in the 1950s ushered in the era of cardiac surgery. The extraordinary technical achievements in coronary artery bypass surgery exerted a disproportionate influence on both thoracic surgical clinical practices and training programs. The delicate balance between resident service and education in thoracic surgery was disturbed. In 1959, The Journal of Thoracic Surgery, the official publication of The American Association for Thoracic Surgery, changed its name to The Journal of Thoracic and Cardiovascular Surgery as an acknowledgment of the importance of cardiac surgery within the specialty. This was a sentinel event in our history, and it contributed substantially to the current inconsistency in how thoracic surgeons are designated. With the rapid progress in myocardial revascularization and the surgical treatment of valvular heart disease, the "thoracic surgeon" became the "cardiac surgeon" to his or her patients and professional colleagues. Some argued that cardiac surgery was sufficiently unique in its scope as to warrant a designation of a specialty separate and distinct from "thoracic surgery" or "noncardiac" thoracic surgery.
However, over the years, the leadership of thoracic surgery has repeatedly reaffirmed the integrity of the specialty. In 1981, Donald Paulson, then President of The American Association for Thoracic Surgery, expressed concern about the status and future of general thoracic surgery within the specialty [1]. Increasingly by default, general thoracic surgery was being performed by general surgeons who did not have a complete thoracic surgery residency education, and thoracic surgery residents focusing largely on cardiac surgery were no longer being taught well the principles of general thoracic surgery. In response, the Liaison Committee for Thoracic Surgery was established by the Council of The American Association for Thoracic Surgery and charged with preserving "unity of the specialty through achievement of appropriate balance in each division of training, in the interest of competence and delivery of quality health care." During the 1980s, the Liaison Committee championed the cause of general thoracic surgery in editorials, reports, and recommendations to the Council of The American Association for Thoracic Surgery, and reemphasized the importance of viewing thoracic surgery as the totality of its subspecialties [2–4]. The General Thoracic Surgical Club was established in 1988 as a national forum for scientific exchange and social interaction between its members. This organization has emerged as a national voice for general thoracic surgery, a term that has now become well-known and well established.
In the 1990s, a veritable crusade on behalf of thoracic surgery resident education began. An editorial symposium on thoracic surgery education appeared in The Annals of Thoracic Surgery in 1991 [5]. The same year, at the thoracic surgery leadership retreat in Snow Bird, Utah, among the several recommendations made was maintenance of "the integrity of cardiothoracic surgery by providing integrated training in both general thoracic and cardiac surgery" [6]. The 1992 Oak Brook, Illinois, Joint Conference on Graduate Education in Thoracic Surgery, organized under the auspices of The Society of Thoracic Surgeons Ad Hoc Committee on Graduate Education in Thoracic Surgery, emphasized the need for more formal curriculum development within our specialty [7]. The Thoracic Surgery Directors Association responded by publishing a Thoracic Surgical Curriculum in 1994, and this encompasses adult cardiac, pediatric cardiac, and general thoracic surgery [8].
Thoracic surgeons certified by the American Board of Thoracic Surgery clearly understand the scope of the specialty and its component areas of specialization. Both The Society of Thoracic Surgeons and The American Association for Thoracic Surgery have designated parallel scientific sessions at their annual meetings for presentation of papers on adult cardiac, pediatric cardiac, and general thoracic surgery. The American Board of Thoracic Surgery and the Residency Review Committee for Thoracic Surgery both continue to require that candidates for certification in thoracic surgery and thoracic surgery residency programs pay appropriate attention to all three components of the specialty.
Despite our understanding of the "Big T" definition of thoracic surgery, inconsistencies in how we, our colleagues, legislators, public policy makers, and the public designate our profession are rampant. Our residents and those applying for residency are confused by the disparity in the designation of our programs at different academic centers (eg, Division of Thoracic Surgery, Division of Cardiothoracic Surgery, Division of Cardiac and Thoracic Surgery). Many of our colleagues in the other medical specialties are unaware that cardiac and thoracic surgery are not synonymous. They do not know that in addition to cardiac surgery, thoracic surgery includes the fields of general thoracic and pediatric cardiac surgery. They need to be educated. The media commonly and erroneously refer to cardiac surgeons as "heart specialists" or "cardiologists." They need to be educated. As legislators, lobbyists, and public policy makers participate in the ongoing debate about reimbursement to health care providers, we need to be consistent and educate them to be consistent in discussions and communications. For example, in considering relative value unit-based reimbursement, the arbitrary division of thoracic surgery operations into "cardiac" and "thoracic" procedures does not acknowledge a separate place for pediatric cardiac surgery. And it is inappropriate that operations of such technical complexity as the arterial switch procedure, the Norwood operation, and the hemi-Fontan, for example, should be weighted equally with an uncomplicated coronary bypass procedure in an adult. Our lobbyists and those with whom they communicate need to understand that "thoracic surgery" refers to a specialty with component parts so that there is clarity about whether adult cardiac, general thoracic, pediatric cardiac surgery, or all three is the topic of discussion. The American College of Surgeons has its Advisory Council on Cardiothoracic Surgery (not Thoracic Surgery) and continues to schedule at its annual Clinical Congress Postgraduate Courses in Cardiac and "Thoracic Surgery," the latter being a general thoracic session; a Friday afternoon specialty session in "thoracic surgery," the latter being a general thoracic session; and the annual Gibbon Lecture in thoracic surgery, in which cardiac, general thoracic, and pediatric cardiac topics have been presented. And we are the only ones who can change these inconsistencies by agreeing to what we are going to call ourselves and then embracing and promulgating the terminology. Acknowledging the wide variation in terminology applied to thoracic surgery and its component subspecialties, The Society of Thoracic Surgeons Ad Hoc Committee on Strategic Directions recently developed a precise definition of thoracic surgery (and its components) [9].
The term "noncardiac" thoracic surgery is an oxymoron, because by definition, the specialty of thoracic surgery includes the heart. Similarly, the term "cardiothoracic" is redundant, because "thoracic" includes the heart. It has been suggested that the word "thoracic" is too difficult for the average patient to pronounce, let alone understand, and perhaps calling ourselves "heart surgeons" and "chest surgeons" would be easier for the public. In my experience, virtually any patient can be taught quickly and understand that "Thoracic surgery is surgery of the chest and its contents. A thoracic surgeon who specializes in heart surgery is a cardiac surgeon; one who specializes in children's heart surgery, a pediatric cardiac surgeon; and one who specializes in all other chest surgery (lungs and esophagus), a general thoracic surgeon." The American public is relatively sophisticated, and we should not consider changing the way we designate ourselves simply to improve marketability. Throughout the world, international journals of "thoracic and cardiovascular" surgery are being established. In different parts of the world, esophageal surgery is not a part of "thoracic" surgery. The existing quagmire of terminology does not benefit any of us. The United States has set the standards for medicine worldwide, and we should be no less precise and demanding in our use of appropriate nomenclature to designate our specialty and its components. With our entry into the 21st century and its emphasis on information technology, the time to standardize is here and now. If the American Board of Thoracic Surgery, the Residency Review Committee for Thoracic Surgery, The Society of Thoracic Surgeons, The American Association for Thoracic Surgery, The Annals of Thoracic Surgery, and other similarly designated organizations and journals are prepared for name changes such as substituting "cardiothoracic" for "thoracic" and having the term "thoracic" come to mean what we now designate "general thoracic surgery," then let's agree and get on with it. Ignoring the issue because "it's just too tough to tackle" is not serving our specialty well. We should come to a consensus about the name of our specialty and its component subspecialties and standardize the definition of thoracic surgery worldwide.
Footnotes
Presented at the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3–5, 1997.
Address reprint requests to Dr Orringer, Section of Thoracic Surgery, University of Michigan Health Care Center, 212 OTC, Box 0344, 1500 E Medical Center Dr, Ann Arbor, MI 48109.
References
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