End Notes
Transition From Residency to ‘‘Independent’’ Congenital Heart Surgeon: A Lifelong Process, not a Graduation Day
World Journal for Pediatric and Congenital Heart Surgery 4(3) 328-329 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135113490761 pch.sagepub.com
Daniel J. DiBardino, MD1 Submitted January 22, 2013; Accepted April 22, 2013.
In the United States, the modern model of surgical residency is directly related to the tradition established by William S. Halsted. Halsted was the first chief of the Department of Surgery at Johns Hopkins Hospital when it opened in May 1889. At Johns Hopkins, Halsted was credited with starting the first formal surgical residency training program in the United States. It was patterned, in part, after the training systems in various parts of Europe. Halsted’s surgical residency program began with an internship. An interesting feature of the training system is that the length was left undefined, and individuals advanced once Halsted believed they were ready for the next level of training. In general, the period of internship was followed by six years as an assistant resident and then two years as a house surgeon. Until recently, most individuals who pursued training in cardiothoracic surgery in the United States did so after completing a residency in general surgery. But this idea, together with many other long-entrenched ideas about surgical training, is currently being challenged and replaced by new alternatives. At the same time, new regulatory efforts, designed to minimize medical errors and improve quality of care, are forever changing the way surgeons are trained. Further work-hour restrictions and regulations are in store; and as the Halsted tradition changes, so does the transition from ‘‘resident’’ to ‘‘trained, practicing surgeon.’’ So drastic is this change that the very definitions (or at least direct implications) of those words seem to be different now than 10 or certainly 20 years ago. The transition from ‘‘surgeon-in-training’’ (resident) to ‘‘trained surgeon’’ has always been difficult in cardiac surgery and perhaps in congenital heart surgery more than any other specialty in medicine. The current era of public sharing of information, particularly through social media, makes scrutiny of surgical outcomes more widespread and more immediate and has forever changed our view of suboptimal outcomes that may be construed as being related, at least in part, to limited surgical experience.1 A young practicing surgeon can ill afford adverse events that might have been viewed as an integral and inevitable part of one’s learning curve in previous generations. And yet, for all the talent and education and training in modern US surgery, there is and always will be a rather long learning
curve in congenital heart surgery. How do we rectify the unstoppable force of expectations with the immovable object of the learning curve? Perhaps it is not a novel question, but the answers are different now. The colloquialism that ‘‘a few eggs must be broken to develop a great chicken farm’’ no longer applies. We, in this specialty, are all familiar with countless early career failures. After completing the ‘‘American Board of Thoracic Surgery Pathway I’’ examination process that followed training at two incredible institutions that offer the very best in training, I navigated my way through the first two years of practice. Although my transition has been successful so far, I have recently become more acutely aware of my own incorrect assumptions regarding the nature of this transition, as I hear them echoed in the remarks of some of those on the verge of making the transition themselves. I believe it might be helpful to communicate my current views regarding this topic, in the hope that they would be of some value to the next generation and also that they might stimulate discussion among those who are long past the learning curve. It is my view that no matter who you are, or where you trained, or for how long, when you are looking for that critical first job you are initially nothing more than a liability. The most important lesson in all of this is to choose the first job for the right reason; and that reason must always revolve around who you are working with, not where. The senior surgeon or surgeons with whom you will work are taking on a liability. As they succeed in assisting you through the learning curve, the assets (payback) include program expansion, their opportunity to take vacation and attend meetings while competent help
1 Department of Surgery, Division of Pediatric and Congenital Heart Surgery, Children’s Heart Center, University of Mississippi Medical Center, Jackson, MS, USA
Corresponding Author: Daniel J. DiBardino, Department of Surgery, Division of Pediatric and Congenital Heart Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA. Email: [email protected]
Downloaded from pch.sagepub.com at OAKLAND UNIV on May 3, 2015
DiBardino
329
stays behind, and possibly the advancement of a center’s reputation for developing junior faculty. What you as the junior surgeon get is obvious; a successful start. When weighing the options, ignore the draw of a potentially ‘‘more well-known name’’ or ‘‘better city’’ and instead focus on the quality of this lifeline. Not all surgeons who say that they are willing to productively assist in this transition truly are doing so; this is a difficult thing to know. Analyzing the senior surgeons’ track record in this regard, or the transition that they themselves were funneled through, can serve as a guide. This is the most important assessment you will make in choosing a job. This genuine effort on the part of the senior surgeons must also be coupled with sufficient case volume. You have to go where you are needed, and being needed means you are going to operate often. I cannot imagine how much harder this would have been while having to simultaneously ‘‘fight’’ other surgeons or centers for case volume. Avoid this at all costs; the most junior person almost always loses these battles. One particularly difficult ‘‘pill for me to swallow’’ was that you will likely be required to adapt to doing things in ways that are different from the familiar system in which you were trained. My senior partner and I made a deal that (because of the fragility of our new program) I had to initially perform the operations as he does. I did not realize when I was shaking his hand over my contract how difficult this would be for me. Lateral tunnel Fontan operations became extracardiac conduits; circulatory arrest was replaced by routine use of regional cerebral perfusion. Remember that it is not permanent; as you succeed, you will inevitably be more and more independent in this regard (I have as of the last year indeed gone back to the ‘‘way I was taught’’ in many respects). Even more surprising (tongue in cheek) was that I actually learned something and changed the process! A lifelong career in this field means constantly learning, especially from your partners and colleagues. The real truth is that there are many acceptable ways to do a Fontan procedure. One can make the best choices after mastering and achieving a comfort level with several of them. Do not be in a hurry under the false guise of ‘‘needing to progress.’’ The old American traditional surgical colloquialisms of ‘‘never say no to a case’’ and ‘‘be a hand surgeon; do
anything you can get your hands on,’’ do not apply in this field. In this era, you must respect your own limitations and comfort level and ask for appropriate senior help when you need it. As I finish my second year in practice, I enjoy having my senior partner scrub with me on all of the complex neonatal cases. I welcome his superior assistance. And when there is trouble, I welcome his skill in guiding me out of trouble. Senior surgeons can most often do this, because they have been in the same trouble. I will certainly be able to do this for someone else someday but not today. Be honest with yourself, welcome a steady successful progression, and know that it is far better to go slower in the race toward ‘‘complete independence’’ than to end up under scrutiny for suboptimal results as a junior staff surgeon. Independence is most often an illusion anyway, as very senior surgeons at major centers can and do call upon other surgeons for help from time to time. Some surgeons always operate with other attending-level physicians. Nothing matters more than the outcome. As I operate with less experienced assistants more and more often, I sometimes miss not having to say a word, and being able to just listen to the radio and operate! Those who always take advantage of continued mentorship will end up with the upper hand in the end. While ‘‘graduation day’’ from congenital heart surgery training does mark the end of a quest of 10 years or more, the concept as such is misleading, and approaching the transition into the role of ‘‘practicing surgeon’’ with this mind-set is dangerous. There are great role models and potential mentors out there; find them and be honest about what you really need, particularly in your first year. Proceed at your own pace, do not lose the ‘‘residency’’ attitude of always learning, and someday you will be ready to support and mentor the next generation. It will, in fact, be your obligation. Reference 1. Cohen M, Jacobs JP, Quintessenza JA, et al. Mentroship, learning curves and balance. In: Anderson RH, Jacobs JP, Wernovsky G, eds. 2007 Supplement to Cardiology in the Young: Controversies and Challenges Facing Paediatric Cardiovascular Practitioners and Their Patients. Cardiology in the Young; vol 17(suppl 2). Cambridge, UK: Cambridge University Press; 2007:164-174.
Downloaded from pch.sagepub.com at OAKLAND UNIV on May 3, 2015
Transition From Residency to ‘‘Independent’’ Congenital Heart Surgeon: A Lifelong Process, not a Graduation Day
World Journal for Pediatric and Congenital Heart Surgery 4(3) 328-329 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135113490761 pch.sagepub.com
Daniel J. DiBardino, MD1 Submitted January 22, 2013; Accepted April 22, 2013.
In the United States, the modern model of surgical residency is directly related to the tradition established by William S. Halsted. Halsted was the first chief of the Department of Surgery at Johns Hopkins Hospital when it opened in May 1889. At Johns Hopkins, Halsted was credited with starting the first formal surgical residency training program in the United States. It was patterned, in part, after the training systems in various parts of Europe. Halsted’s surgical residency program began with an internship. An interesting feature of the training system is that the length was left undefined, and individuals advanced once Halsted believed they were ready for the next level of training. In general, the period of internship was followed by six years as an assistant resident and then two years as a house surgeon. Until recently, most individuals who pursued training in cardiothoracic surgery in the United States did so after completing a residency in general surgery. But this idea, together with many other long-entrenched ideas about surgical training, is currently being challenged and replaced by new alternatives. At the same time, new regulatory efforts, designed to minimize medical errors and improve quality of care, are forever changing the way surgeons are trained. Further work-hour restrictions and regulations are in store; and as the Halsted tradition changes, so does the transition from ‘‘resident’’ to ‘‘trained, practicing surgeon.’’ So drastic is this change that the very definitions (or at least direct implications) of those words seem to be different now than 10 or certainly 20 years ago. The transition from ‘‘surgeon-in-training’’ (resident) to ‘‘trained surgeon’’ has always been difficult in cardiac surgery and perhaps in congenital heart surgery more than any other specialty in medicine. The current era of public sharing of information, particularly through social media, makes scrutiny of surgical outcomes more widespread and more immediate and has forever changed our view of suboptimal outcomes that may be construed as being related, at least in part, to limited surgical experience.1 A young practicing surgeon can ill afford adverse events that might have been viewed as an integral and inevitable part of one’s learning curve in previous generations. And yet, for all the talent and education and training in modern US surgery, there is and always will be a rather long learning
curve in congenital heart surgery. How do we rectify the unstoppable force of expectations with the immovable object of the learning curve? Perhaps it is not a novel question, but the answers are different now. The colloquialism that ‘‘a few eggs must be broken to develop a great chicken farm’’ no longer applies. We, in this specialty, are all familiar with countless early career failures. After completing the ‘‘American Board of Thoracic Surgery Pathway I’’ examination process that followed training at two incredible institutions that offer the very best in training, I navigated my way through the first two years of practice. Although my transition has been successful so far, I have recently become more acutely aware of my own incorrect assumptions regarding the nature of this transition, as I hear them echoed in the remarks of some of those on the verge of making the transition themselves. I believe it might be helpful to communicate my current views regarding this topic, in the hope that they would be of some value to the next generation and also that they might stimulate discussion among those who are long past the learning curve. It is my view that no matter who you are, or where you trained, or for how long, when you are looking for that critical first job you are initially nothing more than a liability. The most important lesson in all of this is to choose the first job for the right reason; and that reason must always revolve around who you are working with, not where. The senior surgeon or surgeons with whom you will work are taking on a liability. As they succeed in assisting you through the learning curve, the assets (payback) include program expansion, their opportunity to take vacation and attend meetings while competent help
1 Department of Surgery, Division of Pediatric and Congenital Heart Surgery, Children’s Heart Center, University of Mississippi Medical Center, Jackson, MS, USA
Corresponding Author: Daniel J. DiBardino, Department of Surgery, Division of Pediatric and Congenital Heart Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA. Email: [email protected]
Downloaded from pch.sagepub.com at OAKLAND UNIV on May 3, 2015
DiBardino
329
stays behind, and possibly the advancement of a center’s reputation for developing junior faculty. What you as the junior surgeon get is obvious; a successful start. When weighing the options, ignore the draw of a potentially ‘‘more well-known name’’ or ‘‘better city’’ and instead focus on the quality of this lifeline. Not all surgeons who say that they are willing to productively assist in this transition truly are doing so; this is a difficult thing to know. Analyzing the senior surgeons’ track record in this regard, or the transition that they themselves were funneled through, can serve as a guide. This is the most important assessment you will make in choosing a job. This genuine effort on the part of the senior surgeons must also be coupled with sufficient case volume. You have to go where you are needed, and being needed means you are going to operate often. I cannot imagine how much harder this would have been while having to simultaneously ‘‘fight’’ other surgeons or centers for case volume. Avoid this at all costs; the most junior person almost always loses these battles. One particularly difficult ‘‘pill for me to swallow’’ was that you will likely be required to adapt to doing things in ways that are different from the familiar system in which you were trained. My senior partner and I made a deal that (because of the fragility of our new program) I had to initially perform the operations as he does. I did not realize when I was shaking his hand over my contract how difficult this would be for me. Lateral tunnel Fontan operations became extracardiac conduits; circulatory arrest was replaced by routine use of regional cerebral perfusion. Remember that it is not permanent; as you succeed, you will inevitably be more and more independent in this regard (I have as of the last year indeed gone back to the ‘‘way I was taught’’ in many respects). Even more surprising (tongue in cheek) was that I actually learned something and changed the process! A lifelong career in this field means constantly learning, especially from your partners and colleagues. The real truth is that there are many acceptable ways to do a Fontan procedure. One can make the best choices after mastering and achieving a comfort level with several of them. Do not be in a hurry under the false guise of ‘‘needing to progress.’’ The old American traditional surgical colloquialisms of ‘‘never say no to a case’’ and ‘‘be a hand surgeon; do
anything you can get your hands on,’’ do not apply in this field. In this era, you must respect your own limitations and comfort level and ask for appropriate senior help when you need it. As I finish my second year in practice, I enjoy having my senior partner scrub with me on all of the complex neonatal cases. I welcome his superior assistance. And when there is trouble, I welcome his skill in guiding me out of trouble. Senior surgeons can most often do this, because they have been in the same trouble. I will certainly be able to do this for someone else someday but not today. Be honest with yourself, welcome a steady successful progression, and know that it is far better to go slower in the race toward ‘‘complete independence’’ than to end up under scrutiny for suboptimal results as a junior staff surgeon. Independence is most often an illusion anyway, as very senior surgeons at major centers can and do call upon other surgeons for help from time to time. Some surgeons always operate with other attending-level physicians. Nothing matters more than the outcome. As I operate with less experienced assistants more and more often, I sometimes miss not having to say a word, and being able to just listen to the radio and operate! Those who always take advantage of continued mentorship will end up with the upper hand in the end. While ‘‘graduation day’’ from congenital heart surgery training does mark the end of a quest of 10 years or more, the concept as such is misleading, and approaching the transition into the role of ‘‘practicing surgeon’’ with this mind-set is dangerous. There are great role models and potential mentors out there; find them and be honest about what you really need, particularly in your first year. Proceed at your own pace, do not lose the ‘‘residency’’ attitude of always learning, and someday you will be ready to support and mentor the next generation. It will, in fact, be your obligation. Reference 1. Cohen M, Jacobs JP, Quintessenza JA, et al. Mentroship, learning curves and balance. In: Anderson RH, Jacobs JP, Wernovsky G, eds. 2007 Supplement to Cardiology in the Young: Controversies and Challenges Facing Paediatric Cardiovascular Practitioners and Their Patients. Cardiology in the Young; vol 17(suppl 2). Cambridge, UK: Cambridge University Press; 2007:164-174.
Downloaded from pch.sagepub.com at OAKLAND UNIV on May 3, 2015
