CORRESPONDENCE
Responses to Minisymposium on Thoracic Surgical Education Should We Care?-Absolutely! Do We Care?-I Do! What Should We Do?-Tough Question! To the Editor: The Editorial Symposium on Thoracic Surgical Education addresses issues of critical importance to our specialty [ I d ] . I would like to offer some thoughts regarding thoracic surgery training. My perspective of the situation is somewhat different than that of the senior cardiothoracic surgeons whose views are presented in the symposium. I completed my residency in general surgery in 1986, and in thoracic surgery in 1988. Since that time, I have held a faculty position (Assistant Professor level) at the University of Miami School of Medicine. My clinical practice includes both cardiac surgery and general thoracic surgery. I am involved in education of medical students, general surgery residents, and thoracic surgery residents. A multitude of factors affect our ability to attract “the best and brightest” into thoracic surgery. The number of medical school applicants has decreased over the past 10 years. There are a number of reasons why college students may not be attracted to medical education. These include factors such as declining reimbursement for health care services, increasing medicolegal risk, increasing governmental regulation, and public dissatisfaction with health care. Currently, it takes at least 15 years to complete college, medical school, surgery residency, and thoracic surgery training. I suspect that further lengthening of training would make it unpalatable to a number of potentially good applicants. However, reducing the length of training could potentially jeopardize the educational infrastructure of the trainees. It is my opinion that the last 2 years of general surgery training are valuable, and that this is not the optimal place for the curriculum to be shortened. It is in the final years of general surgery that residents learn much that will be helpful during cardiothoracic training. This is when they learn to deal with difficult bleeding and with shock. It is worthwhile for the residents to have experience operating on the femoral artery and the carotid artery before we expect them to deal with the pulmonary artery or the intrathoracic aorta. Certainly, a strong background in general surgery is important for esophageal operations. The cardiac surgeon utilizes general surgical training when mobilizing the gastroepiploic artery or inferior epigastric artery for myocardial revascularization. Personally, I have been well served by a strong foundation in general surgery. I believe that the time and energy spent in that period of my training was an excellent investment. I think that most trainees in thoracic surgery are best served by a broad-based comprehensive training program, as currently required by the American Board of Thoracic Surgery. I agree wholeheartedly with Dr Orringer that it is naive to believe that intimately related intrathoracic anatomic structures can be readily separated into different subspecialties [4]. Furthermore, many residents do not know where their specific interests lie until they are well into their training. Some thoracic surgeons-and I am included here-maintain a broad spectrum of practice involving many areas of cardiac surgery and general thoracic surgery. Changes are needed in thoracic surgery training. Appropriate changes will result in better training-not longer, shorter, harder, or easier-but better. This is essential if we are to attract “the best and the brightest“ to thoracic surgery.
Michael D . Horowitz, M D Division of Thoracic and Cardiovascular Surgery University of Miami School of Medicine PO BOX 016960 (R-124) Miami, FL 33101 0 1992 by The Society of Thoracic Surgeons
References 1. Peters RM. Should we care? Do we care? What should we do? Ann Thorac Surg 1991;51:807-8. 2. Grillo HC. Dilemmas in cardiothoracic surgical education. Ann Thorac Surg 1991;51:809-11. 3. Kirklin JW. Training for cardiac surgery in children and adults. Ann Thorac Surg 1991;51:8123. 4. Orringer MB. General thoracic surgery-issues and direction. Ann Thorac Surg 1991;51:814-7. 5. Roth JA, Balch CM. Thoracic surgery training: it is time for a change. Ann Thorac Surg 1991;51:818-9. 6. Benfield JR. What next in cardiothoracictraining? Ann Thorac Surg 1991;51:820.
Thank you for your contribution. Your major point is that the broad clinical practice of cardiac and general thoracic surgery requires the background that is provided by broad-based training programs. You share the concern of many others that reducing the length of the training programs could jeopardize education. As we consider proposals for change in training programs, we must remember that the point in the evolution of training at which we find ourselves now is really quite good. Thoracic surgeons are very competently caring for patients whose diseases call for skills in cardiac surgery and general thoracic surgery. Change for its own sake is certainly to be avoided, but there is general agreement that improvements are needed in certain aspects of most training programs. The question for the future is how best to adapt the existing principles of thoracic surgical training to the reality that increasing complexity of thoracic surgical practice has fostered subspecialization. In fact, each of the authors who contributed to this symposium has gained his reputation primarily as a subspecialist. However, the current leadership in thoracic surgery has also come from a background of broad-based training. Therefore, I am confident that your concern to the effect that reducing the length of training could jeopardize the excellence of education will be kept in mind as change is considered. Moreover, it is clear that there will continue to be a need for thoracic surgeons who practice the broad range of our specialty.
1ohn R. Benfield, M D Division of Cardiothoracic Surgery University of California, Davis 4301 X St, Rm 2320 Sacramento, C A 95818
The Future of Thoracic Surgery, General and Cardiac To the Editor: The Editorial Symposium on the future of thoracic surgery, general and cardiac, in the May 1991 issue of The Annals [1-6] is both timely and welcome. Being a board-certified thoracic surgeon and a member of The Society of Thoracic Surgeons, practicing in a small community for over 25 years, I want to report my observations of this question from a front-line soldier’s perspective. As a whole, the young thoracic surgeons who have settled in this area lately are well trained and good doctors. However, they do lack interest in general thoracic surgery, and I do not believe it is due only to the difference in their residency program. Perhaps the burden of cardiac surgery is so overwhelming that they found their time could be better spent by allowing the Ann Thorac Surg 1992;53:54450
0003-4975/92/$5.00
Responses to Minisymposium on Thoracic Surgical Education Should We Care?-Absolutely! Do We Care?-I Do! What Should We Do?-Tough Question! To the Editor: The Editorial Symposium on Thoracic Surgical Education addresses issues of critical importance to our specialty [ I d ] . I would like to offer some thoughts regarding thoracic surgery training. My perspective of the situation is somewhat different than that of the senior cardiothoracic surgeons whose views are presented in the symposium. I completed my residency in general surgery in 1986, and in thoracic surgery in 1988. Since that time, I have held a faculty position (Assistant Professor level) at the University of Miami School of Medicine. My clinical practice includes both cardiac surgery and general thoracic surgery. I am involved in education of medical students, general surgery residents, and thoracic surgery residents. A multitude of factors affect our ability to attract “the best and brightest” into thoracic surgery. The number of medical school applicants has decreased over the past 10 years. There are a number of reasons why college students may not be attracted to medical education. These include factors such as declining reimbursement for health care services, increasing medicolegal risk, increasing governmental regulation, and public dissatisfaction with health care. Currently, it takes at least 15 years to complete college, medical school, surgery residency, and thoracic surgery training. I suspect that further lengthening of training would make it unpalatable to a number of potentially good applicants. However, reducing the length of training could potentially jeopardize the educational infrastructure of the trainees. It is my opinion that the last 2 years of general surgery training are valuable, and that this is not the optimal place for the curriculum to be shortened. It is in the final years of general surgery that residents learn much that will be helpful during cardiothoracic training. This is when they learn to deal with difficult bleeding and with shock. It is worthwhile for the residents to have experience operating on the femoral artery and the carotid artery before we expect them to deal with the pulmonary artery or the intrathoracic aorta. Certainly, a strong background in general surgery is important for esophageal operations. The cardiac surgeon utilizes general surgical training when mobilizing the gastroepiploic artery or inferior epigastric artery for myocardial revascularization. Personally, I have been well served by a strong foundation in general surgery. I believe that the time and energy spent in that period of my training was an excellent investment. I think that most trainees in thoracic surgery are best served by a broad-based comprehensive training program, as currently required by the American Board of Thoracic Surgery. I agree wholeheartedly with Dr Orringer that it is naive to believe that intimately related intrathoracic anatomic structures can be readily separated into different subspecialties [4]. Furthermore, many residents do not know where their specific interests lie until they are well into their training. Some thoracic surgeons-and I am included here-maintain a broad spectrum of practice involving many areas of cardiac surgery and general thoracic surgery. Changes are needed in thoracic surgery training. Appropriate changes will result in better training-not longer, shorter, harder, or easier-but better. This is essential if we are to attract “the best and the brightest“ to thoracic surgery.
Michael D . Horowitz, M D Division of Thoracic and Cardiovascular Surgery University of Miami School of Medicine PO BOX 016960 (R-124) Miami, FL 33101 0 1992 by The Society of Thoracic Surgeons
References 1. Peters RM. Should we care? Do we care? What should we do? Ann Thorac Surg 1991;51:807-8. 2. Grillo HC. Dilemmas in cardiothoracic surgical education. Ann Thorac Surg 1991;51:809-11. 3. Kirklin JW. Training for cardiac surgery in children and adults. Ann Thorac Surg 1991;51:8123. 4. Orringer MB. General thoracic surgery-issues and direction. Ann Thorac Surg 1991;51:814-7. 5. Roth JA, Balch CM. Thoracic surgery training: it is time for a change. Ann Thorac Surg 1991;51:818-9. 6. Benfield JR. What next in cardiothoracictraining? Ann Thorac Surg 1991;51:820.
Thank you for your contribution. Your major point is that the broad clinical practice of cardiac and general thoracic surgery requires the background that is provided by broad-based training programs. You share the concern of many others that reducing the length of the training programs could jeopardize education. As we consider proposals for change in training programs, we must remember that the point in the evolution of training at which we find ourselves now is really quite good. Thoracic surgeons are very competently caring for patients whose diseases call for skills in cardiac surgery and general thoracic surgery. Change for its own sake is certainly to be avoided, but there is general agreement that improvements are needed in certain aspects of most training programs. The question for the future is how best to adapt the existing principles of thoracic surgical training to the reality that increasing complexity of thoracic surgical practice has fostered subspecialization. In fact, each of the authors who contributed to this symposium has gained his reputation primarily as a subspecialist. However, the current leadership in thoracic surgery has also come from a background of broad-based training. Therefore, I am confident that your concern to the effect that reducing the length of training could jeopardize the excellence of education will be kept in mind as change is considered. Moreover, it is clear that there will continue to be a need for thoracic surgeons who practice the broad range of our specialty.
1ohn R. Benfield, M D Division of Cardiothoracic Surgery University of California, Davis 4301 X St, Rm 2320 Sacramento, C A 95818
The Future of Thoracic Surgery, General and Cardiac To the Editor: The Editorial Symposium on the future of thoracic surgery, general and cardiac, in the May 1991 issue of The Annals [1-6] is both timely and welcome. Being a board-certified thoracic surgeon and a member of The Society of Thoracic Surgeons, practicing in a small community for over 25 years, I want to report my observations of this question from a front-line soldier’s perspective. As a whole, the young thoracic surgeons who have settled in this area lately are well trained and good doctors. However, they do lack interest in general thoracic surgery, and I do not believe it is due only to the difference in their residency program. Perhaps the burden of cardiac surgery is so overwhelming that they found their time could be better spent by allowing the Ann Thorac Surg 1992;53:54450
0003-4975/92/$5.00
