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Ann Thorac Surg 2000;69:330-333
© 2000 The Society of Thoracic Surgeons
a Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
Address reprint requests to Dr Crawford, Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas St, Suite 409, Charleston, SC 29425
Presented at the Forty-sixth Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.
Iam extremely honored to have been chosen to give this first J. Kent Trinkle Lecture in Thoracic Surgery Education for the Southern Thoracic Surgical Association. I am a little intimidated by having it placed between the honored guest address by Dr Shumway, and Dr Baumgardner’s presidential address. This should, however, assure me a captive audience. I should mention that my parents would be particularly proud of me being invited to give this lecture, which is clearly more oriented to education and philosophy than to science, because they were both teachers and were responsible for me choosing a career in academic surgery.
I had the privilege of knowing and working with Kent Trinkle for a long time, most recently during his tenure on the American Board of Thoracic Surgery (ABTS). The ABTS provides the opportunity for a small group of thoracic surgeons to get to know each other extremely well, and Kent and I became close friends. Kent was the source of more bad jokes than any person I have ever known. In San Antonio, these are known as "Trinkleisms." Kent was a strong resident advocate and committed in every sense to thoracic surgery education, to this organization which he served as President, and to the future of our specialty. His death has deprived us of the opportunity to continue to benefit from his wisdom.
For a number of years, a presentation has been given at this meeting by a program director from one of our residency programs. This presentation has usually included a description of that program, and at least a few words about that program’s philosophy of thoracic surgery education. Previous presentations have been made by Ben Wilcox [1], Irv Kron [2], Kent Trinkle [3], and our current and incoming Presidents, Bill Baumgartner [4], and Don Watson. In keeping with their precedent, I would like to first tell you a little about the thoracic surgery residency at the Medical University of South Carolina (MUSC).
The MUSC is the oldest medical school in the southeast. It was founded in 1824, and has been in continuous operation since that time. It is a free standing health sciences university with students in the schools of medicine, dentistry, nursing, pharmacy, health related professions, and graduate studies. It is located in the peninsula portion of downtown Charleston.
In 1948, cardiac surgery was introduced to Charleston when Horace Smithy, a graduate of the University of Virginia School of Medicine and the general surgery residency program in Charleston, utilized a valvulotome to successfully open a stenotic mitral valve in a young lady from Akron, Ohio, who was dying of heart failure secondary to rheumatic mitral stenosis [5]. This was one of the first successful operations on the mitral valve. Tragically Dr Smithy himself died of the same disease later that same year at the age of 34. Eddie Parker, who served this association as president in 1959, subsequently developed the first heart surgery program in South Carolina in Charleston, and we mourned Eddie’s passing last December at the age of 88. Bill Lee was recruited in 1964 to develop a formal residency program in cardiothoracic surgery at MUSC. This program was approved and accredited in 1967, and has been in continuous operation since that time. When Bill died in an automobile accident in 1978, Eddie Parker returned from private practice to run the program until I was recruited in 1979. It has indeed been an honor to be able to return to my home state to help continue the tradition of this program.
At that time, it was a two-year program with two residents in each year, or what is referred to by the Residency Review Committee (RRC), as a 2-2 program. In 1987 we made a conscious decision to change our program from a 2-year to a 3-year program, and to voluntarily decrease the number of residents trained each year from two to one (1-1-1). We believed that additional time would be beneficial in educating the modern thoracic surgeon, and at the same time were concerned about the number of thoracic surgeons being trained. Since my arrival in 1979, 25 residents have completed the program. This map shows where they are currently located (Fig 1). They are in both academic and private practice, and are scattered throughout the country. Only recently have several chosen to remain in South Carolina. Just as is true with all of your residents, ours have been uniformly successful in passing the boards, have been successful in academic and private practice, and accordingly have made our faculty look quite good in the process. We are justifiably proud of all of them.
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As a part of the overall effort of our division, we have been fortunate to develop a very solid basic science research effort under the leadership of Frank Spinale. This effort was initially funded from practice-generated revenues, something that is becoming a thing of the past, but now the program is self-sustaining with over two million dollars in annual extramural funding, including five National Institutes of Health grants. This laboratory has afforded many general surgery residents the opportunity to spend 1 or 2 years in basic cardiovascular research, thus providing them the foundation for the development of an academic career. One of these residents will be presenting at this meeting.
Because of the requirements of the RRC, it is difficult for individual cardiothoracic residency programs to be significantly different from any other. Accordingly our residents participate in a structured educational program, following the curriculum developed by the Thoracic Surgery Directors Association. They benefit from a relatively high volume of both cardiac and general thoracic surgery in addition to our being the only congenital heart and transplant programs in the state. Like Kent Trinkle, we believe that cardiothoracic surgery is not a spectator sport, and accordingly our residents finish the program far exceeding all of the numerical requirements of the RRC and ABTS. Like most cardiothoracic residents, they work extremely hard and receive less help from general surgery residents than in years past. They are assisted, however, by three nurse practitioners and three physician assistants.
One of the unique features of our program is a 3-month elective in the second year. Our resident may spend these 3 months at an institution of his or her choice at our expense, concentrating on an area of particular interest. These elective rotations have included the opportunity for increased exposure in thoracic oncology at Memorial Sloan-Kettering and M. D. Anderson, to valve repair surgery at the Cleveland Clinic, as well as other opportunities. I believe any objective assessment of our residency program would conclude that it is excellent, just as yours are, but it is not as good as it can be, and that brings me to the second part of this address.
I would like to spend a few minutes discussing my views on thoracic surgery education and how we might make the process better. These views are personal and should not be interpreted to necessarily reflect the views of the ABTS, the RRC for Thoracic Surgery, nor the Joint Council for Thoracic Surgery Education, although my tenure on these organizations has obviously influenced my opinion. These views follow the well-established surgical principle of "occasionally (some might say frequently) wrong but never in doubt."
First of all, why change? After all, each of us here today is a product of the current system, and we turned out pretty good, or at least we think so. Furthermore, there are sound reasons not to change including tradition, and the fact that the process works pretty well as it is. Some believe that additional time is not needed for thoracic surgery education. We benefit from getting to select our residents relatively late in the process, after they have had a chance to prove themselves. Finally and not least, the judgment and maturity provided by the chief resident year in general surgery is clearly extremely valuable.
Formal education in thoracic surgery began in 1928 at the University of Michigan, and quickly evolved into a 2-year program that required previous training in general surgery. At that time, thoracic surgeons dealt primarily with inflammatory diseases of the lung, that is to say, tuberculosis and empyema. In 1948, the ABTS was formed, and today, 71 years after the first residency program in thoracic surgery and 51 years after the formation of our Board, the required length of thoracic surgery training remains unchanged at 2 years. General surgery training has always been required as a prerequisite, and certification by the American Board of Surgery (ABS) has been required since 1948.
I submit to you that our specialty has changed significantly in the interim. This slide lists operative procedures commonly performed in 1999, and only those in bold were being performed in 1948 when the ABTS was founded (Table 1). In addition to these new operative procedures, which must be mastered by the thoracic resident, vast increases in one’s fund of knowledge is required in areas such as pharmacology, physiology, immunosuppression, oncology, transplantation, and others, not to mention the recent requirements in coding, compliance, fraud avoidance, etc. My personal view is that additional time devoted to thoracic surgery is therefore necessary to train and educate modern thoracic surgeons, and as I mentioned earlier, we changed to a 3-year program nearly 15 years ago. At the same time, I also believe that the overall length of time required for thoracic surgery education is already too long and that we should not be further increasing the time required for completion of thoracic training.
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I know that few if any of us went into medicine, or specifically cardiothoracic surgery, for purely economic reasons. However, I am concerned as to whether our specialty will continue to be able to attract the best and brightest if we continue to impose the financial hardships required by the length of our educational process, especially when combined with the decreasing reimbursement or reward at the end. In 1999, there were only 167 candidates in the thoracic surgery match for the 139 available positions, not far from a 1 to 1 ratio which would imply that there is a thoracic surgery residency position for just about any general surgery resident who wants one. Even more concerning, the number of U.S. medical school graduates interested in a thoracic surgery residency has steadily decreased. In 1999, only 116 U.S. graduates participated in the match for 139 positions. This was down from 127 only 2 years previously. Somehow until actually preparing for this talk, I had missed the fact that there were significantly more thoracic residency positions available than there were U.S. graduates interested in applying for them.
Another reason for change includes problems associated with graduate medical education funding, both now and in the near future. Some will argue that funding should not be a reason for changing something that has been by any standard extremely successful. Who is going to continue to pay for education 7 to 10 years after medical school? This is a very practical matter, and cannot be ignored. While all residency programs are funded in part by practice-generated revenues, few academic practices will be able to shoulder the additional burden of paying residents’ salaries on top of dean taxes, department taxes, and declining overall revenue.
The idea of significant change in thoracic education is not new. Numerous presidential addresses to the Society of Thoracic Surgeons (Sealy 1971 [6], and Ferguson 1977 [7]), the American Association for Thoracic Surgery (Castanada 1995 [8] and Buckley 1997 [9]), and the Southern Thoracic Surgical Association (Bender 1991 [10]), to mention just a few have advocated change. Conferences devoted to thoracic surgery education, including the Snowbird Conference in 1991 and the Oakbrook Conference in 1992 [11], have also advocated change, and in fact change has occurred. The development and implementation of a curriculum by the Thoracic Surgery Directors Association has been a major step forward. In recent years, the Thoracic Surgery RRC has closed or forced reorganization of programs that have provided poor education or which have emphasized service over education. Resident working conditions, hours, and salaries have significantly improved, but the length of training remains unchanged.
Over the years, numerous discussions have been held with the ABS to explore ways in which thoracic training might be shortened, while at the same time fulfilling the requirements for ABS certification. During this time, requirements for ABS certification, if anything, have become more proscribed and rigid. Many thoracic surgery program directors have been frustrated by the fact that their residents spend most of the first year in thoracic residency studying for the ABS, when we would like to have them concentrating on thoracic surgery. Suggestions as to how this might be changed (as for example substituting the written or qualifying exam in general surgery for the PG-5 in-service exam so that the general surgery resident would only have to complete the oral exam after completion of his residency) have been repeatedly rejected by the ABS. I might add, that such a change would not only benefit thoracic surgery residents, but in fact all residents in general surgery, and especially those entering other fellowships such as plastic surgery, colorectal surgery, pediatric surgery, and vascular surgery.
Will Sealy pointed out in his 1971 presidential address to the Society of Thoracic Surgeons, that many organizations have some influence on thoracic surgery education [6]. The logical corollary of this is that it is extremely difficult to get all these groups to the table at the same time, much less to have them agree on fundamental change. In an attempt to address this problem, the Joint Council on Thoracic Surgery Education was formed in 1996. It is made up of representatives of the ABTS, the Thoracic Surgery RRC, the Thoracic Surgery Directors Association, the American Association for Thoracic Surgery, the Society of Thoracic Surgeons, and the Advisory Council on Cardiothoracic Surgery of the American College of Surgeons. This organization has met several times over the past few years under the leadership of Andy Wechsler as chairman, and the issues regarding thoracic surgery education that I have outlined have been discussed at length.
It finally became clear that the major issue blocking substantive change in thoracic surgery education was the ongoing requirement for ABS certification as a prerequisite to ABTS certification. After a prolonged discussion, which has extended at least throughout my tenure on the ABTS, but which became more focused in the past 6 to 12 months, the ABTS voted unanimously at its fall meeting in October to make ABS certification optional at some time in the future. The reason for making the time of implementation indefinite was to allow all those interested in thoracic surgery education to provide input into exactly how thoracic surgery education should be restructured. This decision by the ABTS, opens the doors for the Joint Council to proceed to make meaningful recommendations regarding the future of thoracic surgery education, with input from the various organizations that have a vested interest. Hopefully some of this input will come from individuals as well, and I encourage you to discuss this with me or any member of the Joint Council. Whether this will result in just some recombination of general surgery and thoracic surgery years, such as 4 and 3 or 3 and 3, or whether it means an entirely new educational process for thoracic surgery, beginning with the PG-1 year after completion of medical school, will be decided as a result of these deliberations. At the very least, a change would mean that we as thoracic surgery educators would have to assume more responsibility for education of our residents, instead of abdicating a good part of it to the general surgery program directors, as is currently the case. Certainly the purpose of this change is not just to add an additional year to thoracic surgery residencies so that the resident can perform more coronary bypass procedures.
Finally, it is very clear that the continued education of a thoracic surgeon is about to become more rigorous and regulated. While our specialty has led with requirements for recertification, a recertification exam, etc, it has recently become abundantly clear that a recertification process on a 10-year cycle which requires undocumented CME and an open book exam, will no longer meet public scrutiny. The recertification process will become more of a maintenance of certification process, will be ongoing and evolving in nature, and will include various ways of assessment of competency such as cognitive expertise and practice performance. As a result the process will be much more rigorous.
In closing, I very much appreciate the opportunity to honor the memory and contributions of Kent Trinkle to thoracic surgery education.
References
This article has been cited by other articles:
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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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