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The Compleat Thoracic-Cardiovascular Surgeon: His Special Training
,Journal of THE T h e Society of Thoracic Surgeons ANNALS and the$ OF THORACIC Southern Thoracic Surgical Association SURGERY VOLUME 1 0 NUMBER 1 JULY 1970
1
I
The Compleat Thoracic-Cardiovascular Surgeon His Special Training Donald B. Effler, M.D.
D
r. Paul Samson was the first person to have served as President of both T h e Society of Thoracic Surgeons and the American Association for Thoracic Surgery. His presidential address, delivered in 1968 before the older Society, expressed concern in matters of training essentials; in it he defined the archaic word compleat as “perfectly equipped and skilled.” Both Dr. Samson and I have borrowed from Izaak Walton* the adjective that will describe the ideally trained thoracic-cardiovascular surgeon today. Incidentally, that good thoracic surgeons are usually competent fishermen has escaped neither Dr. Samson nor myself. As fifth President of this society, it is my privilege to select a subject and to air personal views that may not reflect the collective opinions of this organization. I do so with the confidence that all present are concerned with the training of the compleat thoracic-cardiovascular surgeon. My effort is intended as a critique of the training establishment From the Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, 2020 E. 93rd Street, Cleveland, Ohio 44106. Presidential Address delivered at the Sixth Annual Meeting of Thc Society of Thoracic Surgeons, Atlanta, Ga., Jan. 12-14, 1970. ‘The Coinpleat Angler.
VOL. 10,
NO. I , JULY,
1970
1
EFFLER
and a progress report of pertinent events that have occurred in the two years since Dr. Samson’s address. Thoracic-cardiovascular surgery has, beyond doubt, achieved the status of a pure specialty. It seems incredible that this has come about in a span of time barely exceeding 20 years. The fact that so much can happen in such a short period of time gives strength to the conviction that training essentials are in need of constant reappraisal. All young men who offer their professional lives to the specialty of thoracic-cardiovascular surgery must be given the opportunity to become “perfectly equipped and skilled.” Those responsible for their surgical training are under obligation to maintain high program standards and stay abreast of a rapidly expanding specialty. This will not be accomplished, at least to my way of thinking, in those programs in which the director pays primary homage before the shrine of general surgery. GENESIS
In the beginning, thoracic surgeons evolved from two separate embryos. It was common practice for doctors who were curing from pulmonary tuberculosis to rehabilitate in the operating rooms at their respective sanatoriums; here they might learn by doing procedures that could benefit tuberculous lungs. It was not unusual for a physician whose previous surgical training was meager to graduate from his sanatorium with both an apical scar and a technical facility for performing thoracoplasty, phrenic crush, or empyema drainage. T h e traditional relationship between pulmonary tuberculosis and thoracic surgery constitutes an introductory chapter in this saga of our specialty. The second embryo comes from sturdier stock-that of the healthy general surgeon. Grounded in surgical principles, he brought to thoracic surgery the skill and courage that led to pulmonary resection, esophageal surgery, and excision of mediastinal neoplasia. These surgical milestones were accompanied by advances in pulmonary physiology, endoscopy, anesthesiology, and radiology, all of which were so essential to the practice of thoracic surgery. The general surgeons who pioneered our specialty were basically opportunists, but opportunists with both vision and imagination. Those who still argue in favor of the traditional mixed surgical program invariably cite the simple fact that most of our progenitors were general surgeons. This is true enough, but those general surgeons had one trait in common-the burning desire for self-improvement! T h e Board of Thoracic Surgery was established two decades ago as an affiliate of the American Board of Surgery. T h e infant specialty showed early signs of precocity, but no one anticipated the secondary sex characteristic that would develop later, namely, cardiovascular surgery! The decision to affiliate was based on good reason at the time. 2
THE ANNALS OF THORACIC SURGERY
Training the Thoracic-Cardiovascular Surgeon
Founding members of our board were oriented toward general surgery and were determined that future thoracic surgeons would be well grounded in surgical principles. It was decreed that the new breed of thoracic surgeon would prove manhood by running successive gauntlets of the American Board of Surgery and the Board of Thoracic Surgery. Approximately 2,000 surgeons now wear the twin feathers of dual accreditation; they have willingly accepted the challenge and have proved themselves. But what about the surgical elders who line the gauntlet and wield the flails? Have they kept the faith by providing ideal opportunities for those who are willing to accept the rigors of our specialty training? T o answer the question, let us look at current training practices with the same critical eye that pierces the trainee. T h e original guidelines for approved training in thoracic surgery included three types of programs: (1) the one-year program, (2) the fiveyear mixed program, and (3) the four-and-two-year straight program. T h e One-Year Program. One-year approval was intended primarily for tuberculosis hospitals; however, a rapid decline in pulmonary tuberculosis plus the difficulty that most residents experienced in finding a succeeding year of senior responsibility brought this type of program into disfavor. By edict, one-year approval for training in thoraciccardiovascular surgery is no longer given. T h e Five-Year Mixed Program. This classic program originated in major teaching centers of Boston, Philadelphia, and Baltimore. It prepares the trainee for certification by both boards within a five-year period. Increments of training time in both general and thoracic surgery are intermingled; continuity of time allotted to our specialty is not a feature of the mixed program. In addition, part of the total five-year period may be spent in a surgical laboratory. T h e Beattie Report (Fcb. 1, 1966) states that about 30% of the candidates who have been examined by the Board of Thoracic Surgery are graduates of the five-year mixed programs. T h e Four-and-Two-Year Straight Program. T h e majority of approved programs offer two consecutive years in thoracic-cardiovascular surgery after the candidate completes his requirements in general surgery. Whereas the straight and the mixed programs differ in elements both of time and of continuity, each awards the trainee two separate certificates upon completion. With these wall adornments the graduate trainee may be a general surgeon, a thoracic-cardiovascular surgeon, or perhaps a little bit of each. TODAY
Essentials for training in thoracic surgery were established more than 20 years ago. It is to the everlasting credit of a few men that the VOL. 10, NO. 1, JULY,
1970
3
EFFLER
foundation of a new surgical specialty was established on solid ground, but there is much to be done before the ultimate superstructure is completed. At this stage, two decades beyond groundbreaking, we have not been able to reach basic agreement as to what constitutes an ideal training program for the thoracic-cardiovascular surgeon. It is already apparent that many approved training programs are having difficulty in adjusting to current developments. It is now an established fact that most general surgery programs depend heavily upon exposure to thoracic surgery to bolster the overall program. The written examinations of the American Board of Surgery devote a high percentage of questions to thoracic-cardiovascularsubjects. Oddly, in some institutions the basic general surgery sufferschronic anemia and requires the beef of thoraciccardiovascular surgery to maintain health. For this reason some program directors would dehyphenate thoracic-cardiovascular surgery, returning the thoracic component to general surgery and creating a separate board for cardiovascular surgery. I am confident that this suggestion will have little appeal for those certified by the present Board of Thoracic Surgery. Dehyphenating thoracic-cardiovascular surgery might strengthen some general surgery programs, but overall it would constitute a backward step. Our specialty is devoted to the surgery of cardiac and pulmonary disease; this involves two fundamental systems that are interdependent. T h e essentials of training for thoracic-cardiovascular surgery are in constant need of reassessment. Specialty growth, changing medical economics, and the trend toward stricter specialization in surgery have raised too many unsolved problems. The Society of Thoracic Surgeons is composed primarily of the elite “working class” in this specialty; therefore, it can, if it will, be of help to both the Board of Thoracic Surgery and the Residency Review Committee for Thoracic Surgery in revising current essentials. These two bodies must reflect the collective views of the working specialists in thoracic-cardiovascular surgery. The problems and questions that, in my opinion, must be answered are both timely and provocative. T h e majority of surgeons in private practice are preoccupied with their professional affairs; perhaps this is another example of what has recently been referred to as “the silent majority.” As a result, policy decisions are made by a relatively small group of individuals, most of whom work in an academic atmosphere. This society was founded as a forum for specialists in thoracic-cardiovascular surgery, and if the majority of its members do not take the opportunity of expressing their convictions, its reason for being is unfulfilled. In order that a start be made, a committee (the Ferguson Committee) has been activated to solicit the opinions of all members of The Society of Thoracic Surgeons. My predecessor, Dr. Lyman Brewer, and I believe that this is the first 4
THE ANNALS OF THORACIC SURGERY
Training the Thoracic-Cardiovascular Surgeon
step in determining cross-sectional views of those men who represent our specialty. If there is a need for reappraisal in matters of policy, we might begin by asking questions that are pertinent to the affairs of our specialty. T h e questions I will ask reflect matters that are of deep concern to me. T h e answers represent my own stand and constitute one surgeon’s opinion. 1. Should the Board of Thoracic Surgery continue its a6liation with the American Board of Surgery? T h e American Board of Surgery, from the beginning, has been helpful in its counsel and never dictatorial in matters pertaining to the fledgling specialty of thoracic surgery. From the beginning, our own board members have adopted a policy of inflexible adherence to regulations established by the American Board of Surgery for governing its own affairs. T h e policies that have hampered our handling of Canadian and other foreign-trained surgeons are in reality self-imposed. T h e decision to insist upon double accreditation has put us in a position in which training programs might concern themselves primarily with general surgery and to a lesser degree with thoracic-cardiovascular surgery. This is in no way a criticism of the American Board of Surgery. That body has done its job well and with consistency. During my six-year term as a member of the Board of Thoracic Surgery there was no joint meeting between the boards nor a single meeting attended by a representative of the American Board of Surgery. The limited communication between the two boards was in the form of minutes or routine memos. It was perfectly obvious that each accreditation board is perfectly capable of handling its own affairs and engaging in independent action. Therefore, I conclude that the original reasons for establishing the Board of Thoracic Surgery as an affiliate no longer exist. 2. Does the policy of double certification serve a useful purpose? I believe that ours is the only specialty that subjects its training candidates to this form of double jeopardy. How this came to be has been stated: thoracic-cardiovascular surgeons must be grounded in basic fundamentals of surgery. But this can be accomplished without the requirement of dual certification. I am convinced that many training programs that are oriented toward two separate boards cannot do justice to both. General surgery and thoracic-cardiovascular surgery are separate and distinct entities. T o approve one program for both specialties is now unrealistic. 3. A r e two certificates of particular value to the surgeon who intends to specialize i n thoracic-cardiovascular surgery? It is a fact of professional life that successful consultant practice requires identification with a specific specialty. Few areas within the United States look with favor upon the surgeon who strays between VOL. 10,
NO. 1, JULY,
1970
5
EFFLER
specialty areas. The day of the master surgeon who operated upon various systems of the body whenever the opportunity presented is long gone. Thoracic-cardiovascular surgery has come of age; it is a primary specialty, and for those who intend to practice within its boundaries a single certificate will suffice. The tradition of double certification is a hangover from times past. Continuation of this archaic policy lessens the likelihood of independent status for the Board of Thoracic Surgery. 4. A r e we training too many sul-geons i n thoracic-cardiovascular surgery today? This point is raised with increasing frequency and suggests growing concern over an inflationary trend in our specialty. In my opinion, we are not training enough compleat thoracic-cardiovascular surgeons, but we are awarding an excessive number of certificates! My response is based on eight years of observation while examining for the Board of Thoracic Surgery. Training programs that offer the opportunity for double certification spawn young surgeons who may have no intention of restricting their professional practice to this specialty. T h e Credentials Committee of the Board of Thoracic Surgery is harassed with applications from candidates with marginal qualifications for examination. On occasion, disappointed applicants have muttered threats of legal action, but at no time has this influenced the decision of the Credentials Committee. Over the years, a number of prominent senior surgeons, none of whom are strict specialists in this field, have been examined and certified by the Board of Thoracic Surgery. Therefore, one must make the important distinction between those who receive the best available specialty training and the actual volume who are certified by the Board of Thoracic Surgery. Perhaps it is whimsy on my part, but I am convinced that there will never be too many compleat surgeons in thoracic-cardiovascular surgery. 5. A r e the currently approved training programs adequate to train the compleat thoracic-cardiovascular surgeon? My answer to this is an emphatic no! We must again refer to the essentials that were established more than 20 years ago and then review the changes that have taken place in surgery up to 1970. T h e growth of other surgical specialties plus our own mushrooming progress have encroached upon the territorial boundaries of general surgery. For this reason alone, training essentials and training practices accepted 20 years ago are as much out of date as the crew cut hair style of my youth. Modernizing training programs to meet the needs of the compleat thoracic-cardiovascular surgeon would be simple if we brought general surgery and thoracic-cardiovascular surgery into perspective. This single step would, in my opinion, strengthen our specialty, improve the caliber of training, and eliminate promptly the marginal programs now in operation. For those who are concerned that too many surgeons are 6
THE ANNALS OF THORACICSURGERY
Training the T horacic-Cardiovascu lar Surgeon
being trained for our specialty, I reiterate: Modernize training essentials and the problem will resolve itself! Training essentials in thoracic-cardiovascular surgery can meet the needs of the 1970’s by the simple expedient of reducing the basic general surgical requirements and extending the specialty training time. T h e concept of extended training in thoracic-cardiovascular surgery has been under discussion for a number of years. Drs. Sloan, Kittle, Wheat, and I have discussed this prospect for several years and have appealed to both the Board of Thoracic Surgery and the Residency Review Committee for Thoracic Surgery to permit its implementation. T h e timeliness of our action is attested to by unexpected support from sources outside our specialty. Both the Millis Commission Report and recent policy declarations by the American Board of Surgery have urged approval of experimental or trial programs that will not follow longestablished training ruts. My own version of an extended training program in thoraciccardiovascular surgery will be implemented next July. In its simplest form it is a three-and-three-year program designed exclusively for the surgeon who intends to specialize in thoracic-cardiovascular surgery. T h e trainee begins with three consecutive years of general surgical training; the first year may consist of a straight surgical internship. Upon completion of the basic three years in general surgery, the trainee will undertake three consecutive years of training in thoracic-cardiovascular surgery. T h e first two years of this program constitute junior residency and the final year is the year of senior responsibility. T h e three consecutive years of specialty training will offer the candidate every aspect of our specialty, including exposure to the pulmonary function laboratory and the cardiovascular laboratory. This three-and-threeyear program of extended training in thoracic-cardiovascular surgery is clinically oriented; additional time would be required for the individual who desires six months or more of basic laboratory research. Upon completing the program requirements, the compleat-we hope-thoracic-cardiovascular surgeon may apply directly to the Board of Thoracic Surgery for examination. If successful, he will receive a single, well-earned certificate. CON CL USZON
There are other problems besides those that deal with our interboard relationship, double certification, and adequacy of current training practices. I t is unlikely that all present will agree with the prejudices that have been expressed here today, but my efforts may serve to generate a higher output of catecholamines among those who should be or could be doing more. I think it is reasonable to state that training of VOL. 10, NO. 1, JULY,
1970
7
EFFLER
the compleat thoracic-cardiovascular surgeon must adjust to the growth pattern of the specialty itself. Therefore, it is unlikely that training essentials created more than two decades ago can be completely effective today. The concept of an extended training program for thoracic-cardiovascular surgery is in no sense revolutionary. I prefer to think of it as a natural step in evolution. Extended training programs for this specialty will begin on a trial basis; these initial programs will require careful scrutiny by both the Board of Thoracic Surgery and the Residency Review Committee for Thoracic Surgery. Acceptance of these programs will follow only when all concerned agree that extended specialty training best serves the needs of the compleat thoracic-cardiovascular surgeon. Dr. Samson predicted that the Board of Thoracic Surgery could look forward to troublesome times. Most certainly this would have come to pass had the board been inflexible in thought and incapable of adjusting to current trends. Where it might have floundered, it has, with artful dodging, steered a progressive course and avoided unnecessary collision. The Board of Thoracic Surgery has come of age and has performed commendable service. It has done this by showing a willingness to adjust essentials and philosophies that are in the best interest of this specialty. But it cannot do it alone! The Board of Thoracic Surgery needs the help and the support of that hard core of surgeons who practice the specialty of thoracic-cardiovascular surgery. T h e Society of Thoracic Surgeons will live up to the expectations of its founders if, in good faith, it gives continued support and guidance to the Board of Thoracic Surgery. This accrediting body is perfectly capable of handling its own affairsand guiding the destiny of the young men who will seek and deserve to be compleat thoracic-cardiovascular surgeons.
8
THE ANNALS OF THORACIC SURGERY
1
I
The Compleat Thoracic-Cardiovascular Surgeon His Special Training Donald B. Effler, M.D.
D
r. Paul Samson was the first person to have served as President of both T h e Society of Thoracic Surgeons and the American Association for Thoracic Surgery. His presidential address, delivered in 1968 before the older Society, expressed concern in matters of training essentials; in it he defined the archaic word compleat as “perfectly equipped and skilled.” Both Dr. Samson and I have borrowed from Izaak Walton* the adjective that will describe the ideally trained thoracic-cardiovascular surgeon today. Incidentally, that good thoracic surgeons are usually competent fishermen has escaped neither Dr. Samson nor myself. As fifth President of this society, it is my privilege to select a subject and to air personal views that may not reflect the collective opinions of this organization. I do so with the confidence that all present are concerned with the training of the compleat thoracic-cardiovascular surgeon. My effort is intended as a critique of the training establishment From the Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, 2020 E. 93rd Street, Cleveland, Ohio 44106. Presidential Address delivered at the Sixth Annual Meeting of Thc Society of Thoracic Surgeons, Atlanta, Ga., Jan. 12-14, 1970. ‘The Coinpleat Angler.
VOL. 10,
NO. I , JULY,
1970
1
EFFLER
and a progress report of pertinent events that have occurred in the two years since Dr. Samson’s address. Thoracic-cardiovascular surgery has, beyond doubt, achieved the status of a pure specialty. It seems incredible that this has come about in a span of time barely exceeding 20 years. The fact that so much can happen in such a short period of time gives strength to the conviction that training essentials are in need of constant reappraisal. All young men who offer their professional lives to the specialty of thoracic-cardiovascular surgery must be given the opportunity to become “perfectly equipped and skilled.” Those responsible for their surgical training are under obligation to maintain high program standards and stay abreast of a rapidly expanding specialty. This will not be accomplished, at least to my way of thinking, in those programs in which the director pays primary homage before the shrine of general surgery. GENESIS
In the beginning, thoracic surgeons evolved from two separate embryos. It was common practice for doctors who were curing from pulmonary tuberculosis to rehabilitate in the operating rooms at their respective sanatoriums; here they might learn by doing procedures that could benefit tuberculous lungs. It was not unusual for a physician whose previous surgical training was meager to graduate from his sanatorium with both an apical scar and a technical facility for performing thoracoplasty, phrenic crush, or empyema drainage. T h e traditional relationship between pulmonary tuberculosis and thoracic surgery constitutes an introductory chapter in this saga of our specialty. The second embryo comes from sturdier stock-that of the healthy general surgeon. Grounded in surgical principles, he brought to thoracic surgery the skill and courage that led to pulmonary resection, esophageal surgery, and excision of mediastinal neoplasia. These surgical milestones were accompanied by advances in pulmonary physiology, endoscopy, anesthesiology, and radiology, all of which were so essential to the practice of thoracic surgery. The general surgeons who pioneered our specialty were basically opportunists, but opportunists with both vision and imagination. Those who still argue in favor of the traditional mixed surgical program invariably cite the simple fact that most of our progenitors were general surgeons. This is true enough, but those general surgeons had one trait in common-the burning desire for self-improvement! T h e Board of Thoracic Surgery was established two decades ago as an affiliate of the American Board of Surgery. T h e infant specialty showed early signs of precocity, but no one anticipated the secondary sex characteristic that would develop later, namely, cardiovascular surgery! The decision to affiliate was based on good reason at the time. 2
THE ANNALS OF THORACIC SURGERY
Training the Thoracic-Cardiovascular Surgeon
Founding members of our board were oriented toward general surgery and were determined that future thoracic surgeons would be well grounded in surgical principles. It was decreed that the new breed of thoracic surgeon would prove manhood by running successive gauntlets of the American Board of Surgery and the Board of Thoracic Surgery. Approximately 2,000 surgeons now wear the twin feathers of dual accreditation; they have willingly accepted the challenge and have proved themselves. But what about the surgical elders who line the gauntlet and wield the flails? Have they kept the faith by providing ideal opportunities for those who are willing to accept the rigors of our specialty training? T o answer the question, let us look at current training practices with the same critical eye that pierces the trainee. T h e original guidelines for approved training in thoracic surgery included three types of programs: (1) the one-year program, (2) the fiveyear mixed program, and (3) the four-and-two-year straight program. T h e One-Year Program. One-year approval was intended primarily for tuberculosis hospitals; however, a rapid decline in pulmonary tuberculosis plus the difficulty that most residents experienced in finding a succeeding year of senior responsibility brought this type of program into disfavor. By edict, one-year approval for training in thoraciccardiovascular surgery is no longer given. T h e Five-Year Mixed Program. This classic program originated in major teaching centers of Boston, Philadelphia, and Baltimore. It prepares the trainee for certification by both boards within a five-year period. Increments of training time in both general and thoracic surgery are intermingled; continuity of time allotted to our specialty is not a feature of the mixed program. In addition, part of the total five-year period may be spent in a surgical laboratory. T h e Beattie Report (Fcb. 1, 1966) states that about 30% of the candidates who have been examined by the Board of Thoracic Surgery are graduates of the five-year mixed programs. T h e Four-and-Two-Year Straight Program. T h e majority of approved programs offer two consecutive years in thoracic-cardiovascular surgery after the candidate completes his requirements in general surgery. Whereas the straight and the mixed programs differ in elements both of time and of continuity, each awards the trainee two separate certificates upon completion. With these wall adornments the graduate trainee may be a general surgeon, a thoracic-cardiovascular surgeon, or perhaps a little bit of each. TODAY
Essentials for training in thoracic surgery were established more than 20 years ago. It is to the everlasting credit of a few men that the VOL. 10, NO. 1, JULY,
1970
3
EFFLER
foundation of a new surgical specialty was established on solid ground, but there is much to be done before the ultimate superstructure is completed. At this stage, two decades beyond groundbreaking, we have not been able to reach basic agreement as to what constitutes an ideal training program for the thoracic-cardiovascular surgeon. It is already apparent that many approved training programs are having difficulty in adjusting to current developments. It is now an established fact that most general surgery programs depend heavily upon exposure to thoracic surgery to bolster the overall program. The written examinations of the American Board of Surgery devote a high percentage of questions to thoracic-cardiovascularsubjects. Oddly, in some institutions the basic general surgery sufferschronic anemia and requires the beef of thoraciccardiovascular surgery to maintain health. For this reason some program directors would dehyphenate thoracic-cardiovascular surgery, returning the thoracic component to general surgery and creating a separate board for cardiovascular surgery. I am confident that this suggestion will have little appeal for those certified by the present Board of Thoracic Surgery. Dehyphenating thoracic-cardiovascular surgery might strengthen some general surgery programs, but overall it would constitute a backward step. Our specialty is devoted to the surgery of cardiac and pulmonary disease; this involves two fundamental systems that are interdependent. T h e essentials of training for thoracic-cardiovascular surgery are in constant need of reassessment. Specialty growth, changing medical economics, and the trend toward stricter specialization in surgery have raised too many unsolved problems. The Society of Thoracic Surgeons is composed primarily of the elite “working class” in this specialty; therefore, it can, if it will, be of help to both the Board of Thoracic Surgery and the Residency Review Committee for Thoracic Surgery in revising current essentials. These two bodies must reflect the collective views of the working specialists in thoracic-cardiovascular surgery. The problems and questions that, in my opinion, must be answered are both timely and provocative. T h e majority of surgeons in private practice are preoccupied with their professional affairs; perhaps this is another example of what has recently been referred to as “the silent majority.” As a result, policy decisions are made by a relatively small group of individuals, most of whom work in an academic atmosphere. This society was founded as a forum for specialists in thoracic-cardiovascular surgery, and if the majority of its members do not take the opportunity of expressing their convictions, its reason for being is unfulfilled. In order that a start be made, a committee (the Ferguson Committee) has been activated to solicit the opinions of all members of The Society of Thoracic Surgeons. My predecessor, Dr. Lyman Brewer, and I believe that this is the first 4
THE ANNALS OF THORACIC SURGERY
Training the Thoracic-Cardiovascular Surgeon
step in determining cross-sectional views of those men who represent our specialty. If there is a need for reappraisal in matters of policy, we might begin by asking questions that are pertinent to the affairs of our specialty. T h e questions I will ask reflect matters that are of deep concern to me. T h e answers represent my own stand and constitute one surgeon’s opinion. 1. Should the Board of Thoracic Surgery continue its a6liation with the American Board of Surgery? T h e American Board of Surgery, from the beginning, has been helpful in its counsel and never dictatorial in matters pertaining to the fledgling specialty of thoracic surgery. From the beginning, our own board members have adopted a policy of inflexible adherence to regulations established by the American Board of Surgery for governing its own affairs. T h e policies that have hampered our handling of Canadian and other foreign-trained surgeons are in reality self-imposed. T h e decision to insist upon double accreditation has put us in a position in which training programs might concern themselves primarily with general surgery and to a lesser degree with thoracic-cardiovascular surgery. This is in no way a criticism of the American Board of Surgery. That body has done its job well and with consistency. During my six-year term as a member of the Board of Thoracic Surgery there was no joint meeting between the boards nor a single meeting attended by a representative of the American Board of Surgery. The limited communication between the two boards was in the form of minutes or routine memos. It was perfectly obvious that each accreditation board is perfectly capable of handling its own affairs and engaging in independent action. Therefore, I conclude that the original reasons for establishing the Board of Thoracic Surgery as an affiliate no longer exist. 2. Does the policy of double certification serve a useful purpose? I believe that ours is the only specialty that subjects its training candidates to this form of double jeopardy. How this came to be has been stated: thoracic-cardiovascular surgeons must be grounded in basic fundamentals of surgery. But this can be accomplished without the requirement of dual certification. I am convinced that many training programs that are oriented toward two separate boards cannot do justice to both. General surgery and thoracic-cardiovascular surgery are separate and distinct entities. T o approve one program for both specialties is now unrealistic. 3. A r e two certificates of particular value to the surgeon who intends to specialize i n thoracic-cardiovascular surgery? It is a fact of professional life that successful consultant practice requires identification with a specific specialty. Few areas within the United States look with favor upon the surgeon who strays between VOL. 10,
NO. 1, JULY,
1970
5
EFFLER
specialty areas. The day of the master surgeon who operated upon various systems of the body whenever the opportunity presented is long gone. Thoracic-cardiovascular surgery has come of age; it is a primary specialty, and for those who intend to practice within its boundaries a single certificate will suffice. The tradition of double certification is a hangover from times past. Continuation of this archaic policy lessens the likelihood of independent status for the Board of Thoracic Surgery. 4. A r e we training too many sul-geons i n thoracic-cardiovascular surgery today? This point is raised with increasing frequency and suggests growing concern over an inflationary trend in our specialty. In my opinion, we are not training enough compleat thoracic-cardiovascular surgeons, but we are awarding an excessive number of certificates! My response is based on eight years of observation while examining for the Board of Thoracic Surgery. Training programs that offer the opportunity for double certification spawn young surgeons who may have no intention of restricting their professional practice to this specialty. T h e Credentials Committee of the Board of Thoracic Surgery is harassed with applications from candidates with marginal qualifications for examination. On occasion, disappointed applicants have muttered threats of legal action, but at no time has this influenced the decision of the Credentials Committee. Over the years, a number of prominent senior surgeons, none of whom are strict specialists in this field, have been examined and certified by the Board of Thoracic Surgery. Therefore, one must make the important distinction between those who receive the best available specialty training and the actual volume who are certified by the Board of Thoracic Surgery. Perhaps it is whimsy on my part, but I am convinced that there will never be too many compleat surgeons in thoracic-cardiovascular surgery. 5. A r e the currently approved training programs adequate to train the compleat thoracic-cardiovascular surgeon? My answer to this is an emphatic no! We must again refer to the essentials that were established more than 20 years ago and then review the changes that have taken place in surgery up to 1970. T h e growth of other surgical specialties plus our own mushrooming progress have encroached upon the territorial boundaries of general surgery. For this reason alone, training essentials and training practices accepted 20 years ago are as much out of date as the crew cut hair style of my youth. Modernizing training programs to meet the needs of the compleat thoracic-cardiovascular surgeon would be simple if we brought general surgery and thoracic-cardiovascular surgery into perspective. This single step would, in my opinion, strengthen our specialty, improve the caliber of training, and eliminate promptly the marginal programs now in operation. For those who are concerned that too many surgeons are 6
THE ANNALS OF THORACICSURGERY
Training the T horacic-Cardiovascu lar Surgeon
being trained for our specialty, I reiterate: Modernize training essentials and the problem will resolve itself! Training essentials in thoracic-cardiovascular surgery can meet the needs of the 1970’s by the simple expedient of reducing the basic general surgical requirements and extending the specialty training time. T h e concept of extended training in thoracic-cardiovascular surgery has been under discussion for a number of years. Drs. Sloan, Kittle, Wheat, and I have discussed this prospect for several years and have appealed to both the Board of Thoracic Surgery and the Residency Review Committee for Thoracic Surgery to permit its implementation. T h e timeliness of our action is attested to by unexpected support from sources outside our specialty. Both the Millis Commission Report and recent policy declarations by the American Board of Surgery have urged approval of experimental or trial programs that will not follow longestablished training ruts. My own version of an extended training program in thoraciccardiovascular surgery will be implemented next July. In its simplest form it is a three-and-three-year program designed exclusively for the surgeon who intends to specialize in thoracic-cardiovascular surgery. T h e trainee begins with three consecutive years of general surgical training; the first year may consist of a straight surgical internship. Upon completion of the basic three years in general surgery, the trainee will undertake three consecutive years of training in thoracic-cardiovascular surgery. T h e first two years of this program constitute junior residency and the final year is the year of senior responsibility. T h e three consecutive years of specialty training will offer the candidate every aspect of our specialty, including exposure to the pulmonary function laboratory and the cardiovascular laboratory. This three-and-threeyear program of extended training in thoracic-cardiovascular surgery is clinically oriented; additional time would be required for the individual who desires six months or more of basic laboratory research. Upon completing the program requirements, the compleat-we hope-thoracic-cardiovascular surgeon may apply directly to the Board of Thoracic Surgery for examination. If successful, he will receive a single, well-earned certificate. CON CL USZON
There are other problems besides those that deal with our interboard relationship, double certification, and adequacy of current training practices. I t is unlikely that all present will agree with the prejudices that have been expressed here today, but my efforts may serve to generate a higher output of catecholamines among those who should be or could be doing more. I think it is reasonable to state that training of VOL. 10, NO. 1, JULY,
1970
7
EFFLER
the compleat thoracic-cardiovascular surgeon must adjust to the growth pattern of the specialty itself. Therefore, it is unlikely that training essentials created more than two decades ago can be completely effective today. The concept of an extended training program for thoracic-cardiovascular surgery is in no sense revolutionary. I prefer to think of it as a natural step in evolution. Extended training programs for this specialty will begin on a trial basis; these initial programs will require careful scrutiny by both the Board of Thoracic Surgery and the Residency Review Committee for Thoracic Surgery. Acceptance of these programs will follow only when all concerned agree that extended specialty training best serves the needs of the compleat thoracic-cardiovascular surgeon. Dr. Samson predicted that the Board of Thoracic Surgery could look forward to troublesome times. Most certainly this would have come to pass had the board been inflexible in thought and incapable of adjusting to current trends. Where it might have floundered, it has, with artful dodging, steered a progressive course and avoided unnecessary collision. The Board of Thoracic Surgery has come of age and has performed commendable service. It has done this by showing a willingness to adjust essentials and philosophies that are in the best interest of this specialty. But it cannot do it alone! The Board of Thoracic Surgery needs the help and the support of that hard core of surgeons who practice the specialty of thoracic-cardiovascular surgery. T h e Society of Thoracic Surgeons will live up to the expectations of its founders if, in good faith, it gives continued support and guidance to the Board of Thoracic Surgery. This accrediting body is perfectly capable of handling its own affairsand guiding the destiny of the young men who will seek and deserve to be compleat thoracic-cardiovascular surgeons.
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THE ANNALS OF THORACIC SURGERY