T H E ANNALS OF THORACIC SURGERY Journal of The Society of Thoracic Surgeons and the Southern Thoracic S u r p a l Association VOLUME 20 NUMBER 4

OCTOBER 1975

The Breeding and Feeding of Thoracic Surgeons Herbert Sloan, M.D.

ABSTRACT A brief recapitulation of the history of The American Board of Thoracic Surgery reveals that in its 27-year lifetime it has strived to improve the quality of thoracic surgical training. Most recently the Board has decided that candidates from unapproved programs who begin their training after June 30, 1976, will be ineligible for the Board examination. A population of approximately 2,000 thoracic surgeons should be more than adequate to provide patient care in the United States. At the present rate of certification the thoracic surgeon population would number about 4,000 within 25 years. With the birth rate in the United States nearing zero population growth, the number of new thoracic surgeons trained and certified each year must be limited, and it is imperative that the profession rather than the federal government be in control of this. Continuing education and evaluation of clinical competence will soon be required in the specialty of thoracic surgery. Cooperation among the major groups concerned with thoracic surgery is necessary for successful development of continuing education and the necessary evaluation of competence.

M

'any crucial issues face thoracic surgery today, issues that frequently apply to the entire field of medicine. Problems range from the growing cost of malpractice suits to the complexities of national health insurance . At least some of these, however, should be left to other Society presidents for future presidential addresses. This discussion is limited to the training of thoracic surgeons, the number of thoracic surgeons required to meet the needs of the population, evaluation of clinical competence, and the continuing education of thoracic surgeons.

From the Section of Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Mich. 48104. Presidential Address, with emendations, delivered at the Eleventh Annual Meeting of The Society of Thoracic Surgeons, Montreal, Que., Canada, Jan. 2 1, 1975. I would like to thank Ms. Deborah Bush and Jeanne Tashian for their assistance in the preparation of this material.

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Past presidents of both thoracic societies -Drs. John Strieder [36-381, Paul C. Samson [30], Hiram T. Langston [22], Earle B. Kay [211, Will C. Sealy [321, Robert G. Ellison [141, Donald B. Effler [13], and Benson B. Roe [291- have dealt with these subjects before. Basically, this address attempts to respond to some of the challenges raised by these previous presidents, especially Dr. Roe’sclarion call to thoracic surgeons to lead the medical profession in reform measures that will improve the quality of medical care, strengthen the image of the profession, and forestall government interference.

Training The development of programs for training thoracic surgeons (Fig. 1) can be reviewed from one standpoint by a brief recapitulation of the history of The American Board of Thoracic Surgery (ABTS).* In 1937 a committee of The American Association for Thoracic Surgery discussed the possibility of a separate board for thoracic surgery, but the idea was dismissed as inappropriate (Fig. 2). *From records of The American Board of Thoracic Surgery and L. Sper, personal cornrnunications, 1974-75.

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FIG. 2 After all, there were fewer than two dozen men in the United States at that time whose practice was limited to thoracic surgery. In addition, The American Board of Surgery had just been established. Nonetheless, training programs in thoracic surgery were already evolving. Dr. John Alexander had directed a training program at the University of Michigan since 1928. His ideas about training closely paralleled the programs we know today, which call for two years of training in thoracic surgery following training in general surgery [21. World War I1 sparked the development of a larger number of thoracic surgeons and showed the value of special care for thoracic injuries. With this stimulus those people practicing thoracic surgery felt much more strongly that a specialty board was needed, and in 1948 The Board of Thoracic Surgery was established as an affiliate of The American Board of Surgery. Numerous changes in the requirements of The Board of Thoracic Surgery over the ensuing 27 years led to continued improvement in thoracic surgical training. In 1950 The Board of Thoracic Surgery established a mechanism to evaluate thoracic training programs. Advance approval or accreditation of socalled mixed programs was abolished in 1963 [38]. A tripartite Residency Review Committee with representatives from the American College of Surgeons, the American Medical Association, and the Board in 1967 took over evaluation of training programs, a duty which had previously been carried out by the Board and the AMA Council on Medical Education. In 1969, at the recommendation of the Committee on Standards of the Advisory Board for Medical Specialties (which was soon going to reconstitute itself as the American Board of Medical Specialties), The Board of Thoracic Surgery abandoned its affiliate status and became a primary board (Fig. 3). It then voted to

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FIG. 3 change its name to The American Board of Thoracic Surgery effective January 1 1971. Under the leadership of Drs. David Dugan, Donald Paulson, and C. Frederick Kittle, the Board entered its “modern era” of more rapid changes in thoracic training. It was decided that trainees must have a year of senior responsibility. Members of the Board became increasingly concerned about the caliber of some of the approved training programs. In 1971 Dr. Myron W.Wheat, Jr., reviewed 18such programs, representing 160 candidates, and found that the failure rate on the Board examination ranged from 30 to loo%, more than one-half the trainees were foreign medical graduates, and poor clinical experience was provided. This led the Board to decide in 1971 that it should reserve the right to review and reject applications of candidates whose training had started January 1, 1972, or later, who may have come from approved programs but whose operative experience was below the thirtieth percentile of all candidates applying for examination (Fig. 4). A second decision in October, 1973, ruled that poor concentration of experience might also be reason for the ABTS to reject a candidate who started training July 1, 1974, or later. A great deal of discussion centered around the difficult problem of what constitutes an adequate volume of clinical experience. The Residency Review Committee for Thoracic Surgery, under the leadership of Dr. James Malm with input from the ABTS, established the criterion that 100 major cases in which the candidate is the responsible surgeon should be performed during a 2-year training period. Of these major operations, 15 to 20 should involve the lungs or pleura, 30 to 40 should be cardiac, and 5 to 10 should involve the esophagus or diaphragm. )

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FIG. 4

Major improvements were made in the examination itself with the adoption of a 200-question multiple-choice test prepared with the help of the National Board of Medical Examiners (Fig. 5). Substantial changes in the oral portion of the examination were also made. The Board owes a great debt to Drs. Donald Paulson, C. Frederick Kittle, Paul C. Adkins, and Thomas B. Ferguson, under whose direction these changes were accomplished. In its efforts to evaluate the quality of thoracic training and to provide some flexibility in the way a candidate might spend his training years, the ABTS established trial training programs in five institutions. These provide 3 years of training in general surgery and 3 years in thoracic surgery (Fig. 6) with trainees allowed to take the ABTS examination without prior certification by The American Board of Surgery. Evaluation is continuing, and no absolute conclusions have been reached about the value of these programs [431. In 1974 a limit was set on how long a candidate may wait to take the Board examination: candidates finishing their training after January 1,1975, and applying for examination more than 5 years after satisfactory completion of their residency must have an additional year of training in an approved program to be eligible to apply for examination. In 1974 it was also decided that candidates for certification who fail the examination three times must satisfactorily complete an additional year of training in an approved program before they will be considered for examination a fourth time. Perhaps the most controversial decision made by the Board was to refuse examination to candidates from unapproved programs. This decision disqualifies

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any candidate who will begin training after June 30, 1976, in an unapproved program (Fig. 7). Shock waves are still reverberating u p and down the Eastern seaboard, but the ABTS is one of the only specialty boards still examining candidates from unapproved programs. While certain programs in the most prestigious centers of learning have never sought approval but d o train superb sur-

FIG. 6 376

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Breniitig nrid Feeding of Thoracic Surgeons

geons, many of the unapproved programs are marginal, and the failure rate for candidates in these programs is high. T h e Board's action will decrease the number of candidates taking the examination each year by approximately 50 persons. It is to be expected, however, that some institutions not now approved will be before the 1976 deadline. Slightly more than 200 certificates were issued after the 1972 examination, but by 1975 the number had dropped to 141 (Fig. 8). A total of 3,150 surgeons have been certified by the Board since 1950,228 from the Founder's Group and 2,922 by examination. A growing proportion of foreign graduates are being certified, not only in thoracic surgery but in virtually all the major specialties. Differences in performance between candidates graduating from medical schools in the United States and Canada and those from other medical schools is an extremely sensitive subject, which, nonetheless, must be looked at clearly. T h e performance of foreign medical graduates has not been as good as that of their counterparts from the United States and Canada [28] (Fig. 9). COMPARATIVE PERFORMANCE OFGRADUATES

DIPLOMATES CERTIFIED ANNUALLY

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200

11973 NOEXAMGIVEN) (1974-7s CAWLNANSIIREMICLUDED WITH U S GRAWAl'ESI

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c--4 US. GRADUATES C.

FOREIGN GRADUATES 1

1960

1

1

1

1

1

I

1970

1965

I

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YEARS

FIG.. 9 VOL. 20, NO. 4, OCTOBER, 1975

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While the Residency Review Committee is responsible for improving training programs in thoracic surgery, liaison between the Board and the Committee in the past has left something to be desired. This liaison has improved, and there is now a continuous interchange of information between the two bodies. The Board and the Residency Review Committee have also attempted to strengthen their relationships with the directors of training programs, and the Board has begun to include more program directors in the examination process. In his superb presidential address before the Society, Dr. Will Sealy [32] emphasized the need for cooperation between the Residency Review Committee, the ABTS, and the directors of thoracic surgical residency programs (Fig. 10).He urged that program directors take decisive action to eliminate poor candidates either before they are accepted into programs or during their training. The ABTS examination is not the place to weed out individuals who cannot be thoracic surgeons. T o put candidates through the time and expense of thoracic training, realizing they will not be good surgeons, and to expect the Board to fail them is an extremely poor way to handle the unsuitable candidate.

Manpower The question of how many thoracic surgeons are needed probably cannot be answered definitively,*but a valiant effort was made by Dr. Lyman Brewer and his co-workers when they conducted the National Thoracic Surgery Manpower Study [ 7 ] .Though underfunded and understaffed, it is still probably better than any *E. Carpenter, personal communication, 1974.

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Breeding mid Feeding of Thoracic Surgeons other manpower study undertaken in the surgical specialties, and a great deal of credit is due t o Dr. Brewer and the men who worked with him. .As ;I part of this study. thoracic surgeons were asked how much work they do each year. The response from 1.17 1 Board-certified surgeons was that they work 48 weeks per year 011 the average and perform in toto 165,644 major thoracic operations. This nieaiis that if the work were distributed equally among these individuals. each would perform just under three major operations per week. It can be questioned whether this represents the best utilization of manpower in thoracic surgery or whether a smaller number of surgeons might adequately serve the population. Dr. Brewer’s study also showed that 30%of all thoracic operations were being done by individuals not certified in the specialty. Yet, even if it were decided tomorrow that Board certification in thoracic surgery is necessary in order to open the chest and this increased workload were handed to the Boardcertified thoracic surgeons, the number of operations each would perform would increase to just four per week. The study was conducted before the major impact of coronary artery surgery was being felt. However, there are indications that the number of coronary artery operations done per year is leveling off and that these operations will not continue to increase exponentially. In short, it is difficult to make a case that there are too few thoracic surgeons in the United States today. It is estimated that about 2,000 active Board-certified thoracic surgeons are currently available. If we continue to certify 150 to 200 new people each year, by the year 2000 A.D. there will be 4,000 card-carrying thoracic surgeons in the United States. This computation takes into account people who drop out of the field, retire, leave the country, go into administration, or die. While the population of the United States is still increasing at about 0.7% per year, the birth rate continues to drop steadily, and it does not seem realistic to assume that we will need double the number of thoracic surgeons in 25 years for a country very close to zero population growth or for the anticipated needs of the specialty. Synthesizing this information, it is estimated that about 70 new thoracic surgeons per year would be needed to maintain a population of 2,000 practicing thoracic surgeons in the United States. Studies in other surgical specialties using different formulas have arrived at similar conclusions [4, 101. Neurological surgeons have been wrestling with their manpower problem for several years now. There are approximately 2,600 neurosurgeons in this country performing an average of 150 to 180 operations each per year. This is about twice the proportion of neurosurgeons found in Canada and about five and one-half times the ratio in Great Britain. It has been recommended that the number of neurosurgeons trained per year be cut back by 25%.* Looking at the data from another standpoint, in Australia there are approximately 3.5 thoracic surgeons per million population;? in England this figure is 2.5 thoracic surgeons for every million;$ Canada has about 4 thoracic surgeons per *R. C. Schneider, personal communication, 1975. tP. Clarke and H. D. Sutherland, personal communication, 1974. SS. Lennox, personal communication, 1974.

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SLOAN million. If the United States were to have an equivalent ratio of thoracic surgeons to population, we would need about 650 thoracic surgeons. Such comparisons do not, of course, make allowance for differences in practice between these other countries and the United States, such as availability of beds, waiting lists, or philosophies of treatment. By almost any method of examining the data, though, it appears we do not need to increase the number of thoracic surgeons already practicing in this country. Certainly 100 new thoracic surgeons per year would be more than adequate. Eliminating candidates from unapproved programs may provide this reduction. At present it is not a responsibility of the Residency Review Committee to determine the number of thoracic surgeons required; their duty is to examine training programs and determine whether candidates have received satisfactory training. However, it is now necessary for the specialty of thoracic surgery to examine manpower needs and make some decision about the number of new surgeons required. Any effort of this sort should involve both the major thoracic societies and the Residency Review Committee in cooperation with program directors. It is important to recognize that the federal government has been looking at this problem carefully (Fig. 11). The Health Manpower Act of 1974 [181, a bill that passed both houses of Congress last year and has been introduced again, proposes that the number of first-year residencies in the United States be decreased from the present level of 169%of United States medical school graduates to 125% by 1978, with preference being given to graduates of United States medical schools. It also provides that 55% of available residencies be in primary care, compared with the present 37% of first-year residency positions. With the simultaneous reduction in numbers of residency positions and the increased proportion delegated to primary care, it seems obvious that thoracic surgery,

FIG. 11 380

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Breeding and Feeding of Thoracic Surgeons along with many other fields, will find the number of its training positions reduced (Fig. 12). Under this legislation the Secretary of Health, Education, and Welfare would oversee residency requirements through two agencies, one responsible for review and accreditation of each medical residency program in the United States and the other designating the residency positions to be available. T h e Liaison Committee for Graduate Medical Education (LCGME) has been recommended for the former function and the Coordinating Council on Medical Education (CCME) for the latter. It is most important that our Residency Review Committee, supported by the two societies and the program directors, be prepared to make proposals to the LCGME and CCME about numbers and kinds of thoracic surgeons needed, rather than having this done for us by groups with less information about the field.

Continuing Education and Evaluation of Clinical Competence There are many aphorisms regarding the need to renew expertise in the scientific professions: if you don’t continue to educate yourself, you face partial obsolescence in 5 to 10 years; scientific knowledge doubles every 10 years; the half-life of biological knowledge is only 6 years (Fig. 13). While these premises may not withstand the most careful examination, philosophically they are true. I n 1950 the following subjects were covered on the ABTS written examination: * 1. History of thoracoplasty 2. Physiology of “tight” mitral stenosis 3. Anatomy of the vagus nerve 4. Histoplasmosis 5. Pathogenesis of lung abscess 6. Cause of acute hemoptysis 7. Nonexpansible lung after pneumothorax 8. Pancoast’s syndrome 9. Nutrition in esophageal carcinoma 10. Pneumococcal empyema

While still relevant to thoracic surgery, these subjects can hardly be said to encompass the field; knowledge about thoracic disease has increased so tremendously that this examination simply would not be adequate today. Continuing education of the thoracic surgeon, as well as of most other medical specialists, has become a fact of life which we can no longer ignore. A few other straws are in the wind, and attendance at meetings of The Society of Thoracic Surgeons is one of them. T h e Society has 5-year attendance records for 955 of its members that show a discouragingly large number of individuals who have attended only two, one, or no meetings (Table).? While many groups offer continuing education that is of value to our specialty, this meeting is the *L. Sper, personal communication, 1975. t W . Purcell and B. Perkins, personal communication, 1974.

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FIG.

forum for practicing thoracic surgeons, and one can only conclude that there is relatively widespread indifference to combating obsolescence. Another indicator is the self-assessment examination offered by the ABTS this year. Unfortunately, the distribution of material through the mails went awry, and many of the examinations could not be returned when they should have been. Granting that, one-third of the people who paid $75 to take the examination and could have returned it on time did not. Again, continuing education and selfassessment do not seem to loom very large in the lives of these thoracic surgeons. Data from the self-assessment examination show that, overall, those thoracic surgeons who did least well on both the cardiac and general thoracic parts were

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farthest from their residency training.* It must be pointed out that not everyone took both sections. However, of those who did, individuals specializing in cardiac surgery performed better than those whose practice consists mainly of lung and general thoracic operations. Surgeons involved in academic medicine seemed to do better; but it can be argued that the questions asked were not relevant to the daily experience of a practicing thoracic surgeon. This is a key issue in defining “clinical competence” and should, be given careful consideration. Recognizing the need for continuing education to keep surgeons abreast of the times raises the problem of determining clinical competence. Mandatory evaluation of clinical competence is an increasingly emotional subject (Fig. 14). The ABTS has ruled that all candidates certified in March, 1976, and after must have their certificates renewed every 10 years. This regulation does not apply to any candidate presently certified. The way in which clinical competence will be determined is not known today. An ad hoc committee of the ABTS composed of Drs. Robert G. Ellison, W. Sterling Edwards, and Ralph D. Alley has defined it in the following way: Clinical competence in thoracic and cardiac surgery is the demonstrated ability to provide a quality of patient care that measures up to those portions of a set of national standards which are applicable to the profile of an individual thoracic surgeon’s practice. No one believes that clinical competence for the practicing thoracic surgeon can be measured on the basis of a didactic examination alone. It seems highly likely that clinical competence will be determined through demonstrated participation in continuing education, some kind of survey of patient practice, and an objective examination. A number of regional thoracic societies have already declared themselves absolutely opposed to mandatory recertification. Nonetheless, some such evaluation will be necessary, and we had best prepare for it. The ABTS has decided that determining clinical competence lies within its sphere of activity but that continuing education must depend on the societies and the American College of Surgeons. N o program in continuing education, however, will be formulated without a major cooperative effort among the groups interested in thoracic surgery. Again, *L. Sper, personal communication, 1975.

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FIG.

14

Dr. Lyman Brewer merits our thanks for introducing the concept of a “coordinating council,”consisting of members of the two societiesand the American College of Surgeons, which will be responsible for developing continuing education in the specialty [6]. Comment The future of thoracic surgery is still as bright and exciting as it was in the early 1950s when the monumental advances in cardiac surgery that we had only dreamed of before actually materialized. Not only is our specialty rapidly changing, but the entire medical profession is in turmoil about the future of medicine in the United States.Three points are crucial to our continued vigor during this time of transition. 1. Better cooperation is needed between the ABTS, the Residency Review Committee, and the program directors to improve the quality of thoracic surgical training. Our interchanges must be expanded and our efforts better integrated since we are all working toward the same goal, to train excellent thoracic surgeons. 2. The manpower problem must be faced. The societies and the ABTS must support the Residency Review Committee in its efforts to make recommendations about the number of thoracic surgeons needed in this country. 3. We must resign ourselves to the inevitability of continuing evaluation of clinical competence and put aside our fears of it. Ongoing evaluation of clinical competence should be viewed as an important means of helping us provide better medical care in our chosen field.

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References 1. Adkins, P. C., Wheat, M. W., and Ferguson, T. B. Poll on thoracic surgical training. A n n Thorac Surg 13:44, 1972. 2. Alexander, J. The Collapse Therapy of Pulmonary Tuberculosis. Springfield, 111.: Thomas, 1937. P p 19-22. 3. American Board of Medical Specialties. Annual Report, 1973. 4. American Board of Medical Specialties. Specialty Manpower and the Accreditation and Allocation of Residencies. In Summary, Reports by Members, 1974. 5. Barker, H. G. (Ed). The ContinuingEducation of the Surgeon. Springfield, Ill.: Thomas, 1971. 6. Brewer, L. A. A heritage and a challenge (presidential address).J Thorac Cardiouasc Surg 68:177, 1974. 7. Brewer, L. A., Ferguson, T. B., Langston, H. T., and Weiner, J. M. National Thoracic Surgery Manpower Study, 1974. 8. Brondos, G. A. Questions about recertification (correspondence). N Engl J Med 290:1384, 1974. 9. Chase, R. A., Moore, F. D., Anlyan, W. G., Warren, R., and Duval, M. K. Surgical manpower: A symposium. Arch Surg 108:637, 1974. 10. Council of Medical Specialty Societies. Summary of Responses on Information from Member Organizations Concerning Residency Programs and Manpower Studies, 1974. 1 1 . Curreri, P. W., Zimmerman, C. E., Jaffee, B. M., MacKenzie, J. R., Nancy, F. C., Zollinger, R. M., Jr., and Gardner, B. Survey of employment satisfaction in academic surgery. J Surg Res 17:215, 1974. 12. Dugan, D. J. Residency training programs in thoracic and cardiac surgery - 1972 (editorial). A n n Thorac Surg 13:82, 1972. 13. Effler, D. B. T h e compleat thoracic-cardiovascular surgeon: His special training (presidential address). A n n Thorac Surg 10:1 , 1970. 14. Ellison, R. G. Significant events in the history of T h e Society of Thoracic Surgeons. A n n Thorac Surg 14:577, 1972. 15. Fonkalsrud, E. W. Reassessment of surgical specialty training in the United States (editorial). Arch Surg 104:759, 1972. 16. Fry, W. J. Education of the surgeon. Arch Surg 1103372, 1975. 17. Hanlon, C. R. Production and distribution of surgeons in the United States. Bull A m Coll Surg 59: 17, 1974. 18. Health Manpower Act of 1974. HR Report no. 93-1509, Nov 29, 1974. 19. Hughes, E. F. X., Fuchs, V. R., Jacoby, J. E., and Lewit, E. M. Surgical work loads in a community practice. Surgery 71:315, 1972. 20. Hughes, E. F. X., Lewit, E. M., and Rand, E. Operative work loads in one hospital's general surgical residency program. N Engl J Med 289:660, 1973. 21. Kay, E. B. Presidential Address 1974: I. Professional Standards Review Organizations and their implications for physicians. A n n Thorac Surg 18:105, 1974. 22. Langston, H. T. Of cabbages - and kings.] Thorac Cardiouasc Surg 60: 151, 1970. 23. Lublin, J. S. Do doctors need a check up? Wall St J , Feb 24, 1974. 24. Malm, J. R. Thoracic training programs as evaluated by the Residency Review Committee. J Thorac Cardiouasc Surg 66:158, 1973. 25. Miller, L. D., Saxbe, W. B., Jr., Hughes, E. F. X., Bergland, R. M., ONeill, J. A,, Jr., Ravitch, M. M., Barton, B., Spencer, F. C., and Moore, F. D. T h e training of surgeons: How many, in what and by whom. Surgery 76:170, 1974. 26. Moore, F. D. Freedom and organization. Ann Surg 176:1, 1972. 27. Moore, F. D. T h e production, attrition, and biologic lifetime of surgeons in relation to the population of the United States: A look into the future through the clouded computer crystal. Ann Surg 176:457, 1972. 28. Ravitch, M. M. Why are so many failing the surgical boards? Board Rev, November 1974. 29. Roe, B. B. Whither in maturity? (presidential address). A n n Thorac Surg 15:553, 1973.

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SLOAN 30. Samson, P. C. General surgery and the thoracic surgeon (presidential address). AmJ Surg 126:127, 1973. 31. Scannell, J. G., Brown, G. E., Ellison, R. G., Groves, L. K., Laufman, H., Sabiston, D. C., Sloan, H., and Wheat, M. W. Optimal resources for cardiac surgery. Ann Thorac Surg 12:213, 1971. 32. Sealy, W. C. Residents and residencies (presidential address). Ann Thorac Surg 12:561, 1971. 33. Sloan, H. S. The winds of change (editorial). Ann Thorac Surg 6:413, 1968. 34. Spencer, F. C. The surgical residency: Length and quality. Surgery 74:791, 1973. 35. Sper, L. Recollections. American Board of Thoracic Surgery, 1973. 35a. Stimmel, B. The Congress and health manpower: A legislative morass. N Engl J Med 293:68, 1975. 36. Strieder, J. W. The training of the thoracic surgeon (editorial). Ann Thmac Surg 1:363, 1965. 37. Strieder, J. W. Training thoracic surgeons. Univ Mich Med Cent J 34:73, 1968. 38. Strieder, J. W. Aesculapius contemplates thoracic surgery (presidential address). J Thorac Cardiovmc Surg 64:169, 1972. 39. Warren, R., and Haber, C. D. The foreign graduate as surgical resident. Surgery 70:546, 1971. 40. Weiss, R. J., Kleinman, J. C., Brandt, U. C., Feldman, J. J., and McGuinness, A. C. Foreign medical graduates and the medical underground. N Engl J Med 290:1408, 1974. 41. Weiss, R. J., Kleinman, J. C., Brandt, U. C., and Felsenthal, D. The effect of importing physicians - return to a pre-Flexnerian standard. N Engl J Med 290: 1453, 1974. 42. Welch, C. E. Too many surgeons? (editorial). Surgery 76: 199, 1974. 43. Wheat, M. W. Special training programs in thoracic surgery (editorial). Ann Thorac Surg 15:661, 1973. 44. Whipple Surgical Society. The Training of Surgeons in the Future. Springfield, Ill.: Thomas, 1968.

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The breeding and feeding of thoracic surgeons.

A brief recapitulation of the history of The American Board of Thoracic Surgery reveals that in its 27-year lifetime it has strived to improve the qua...
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