- Email: [email protected]
The continuing dilemma of general thoracic surgery
Volume 97,
Number 5
May 1989
THORACIC AND CARDIOVASCULAR SURGERY The Journal
J
THORAC CARDIOVASC SURG
of
1989;97:649-53
Original Communications
The continuing dilemma of general thoracic surgery Where to now? Mark B. Orringer, MD, Ann Arbor, Mich., Joel D. Cooper, MD, St. Louis, Mo.. George Magovern, MD, Pittsburgh, Pa., James Mark, MD, Stanford, Calif., Martin McKneally, MD, Albany, N.Y, and Watts Webb, MD, New Orleans, La.
In
1981, in his presidential address to The American Association for Thoracic Surgery entitled "A Time for Assessment," Dr. Donald Paulson! expressed the growing concern of a number of leaders in this specialty about the status and future of general thoracic surgery. The tremendous technologic advances in cardiac surgery since the early 19508 and the impact of myocardial revascularization had relegated general thoracic surgery to a secondary role, and at many hospitals segments of this field had already been lost by default to surgeons with minimal thoracic training. In response to Dr. Paulson's .recommendations, the Council of the AATS later in 1981 appointed the Liaison Committee for Thoracic Surgery, charged with preserving "unity of the specialty through achievement of appropriate balance in each division of training, in the interest of competence in the delivery of quality health care." The original committee, chaired by Dr. Hermes Editor's Note: The authors of this manuscript constitute the Liaison Committee for Thoracic Surgery of The American Association for Thoracic Surgery; Chairman, Mark B. Orringer, MD. Received for publication Dec. 5, 1988. Accepted for publication Dec. 5, 1988.
C. Grillo, consisted of Drs. John Benfield, L. Penfield Faber, Donald G. Mulder, F. Griffith Pearson, Richard M. Peters, and Benson B. Roe. The committee developed a questionnaire that was used to survey thoracic surgery program directors and assess the relative emphasis being given to general thoracic surgery in resident education. The data from this survey formed the basis of a report to the Council of the AA TS in April 1983. On the assumption that an ideal thoracic surgery training program should provide each of its residents with 1DO major general thoracic and 100 major cardiac surgical procedures during his training, only 41% of the 85 teaching programs responding to the survey showed the appropriate balance; 14% were below standard and 45% were imbalanced. (Eleven programs did not respond.) Myocardial revascularization dominated residency training, and esophageal surgery was virtually absent in many programs. It was concluded that "general thoracic surgery is undersupported in (1) time and quality of instruction, (2) availability of case material, (3) assignment of case material to residents, (3) accessibility to beds and operating time, and (5) research funding." 649
6 50
Orringer et al.
A subsequent editorial appeared in both THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERy2 and The Annals of Thoracic Surgery? outlining the recommendations of the Liaison Committee, endorsed by the Council of the AATS, and intended to help remedy these deficiencies. Recommendations in principle were made to thoracic surgery program directors with the intent of increasing the emphasis on general thoracic surgery in residency training. These included (1) identifying specific faculty members responsible for instruction in general thoracic surgery; (2) designating beds, operating time, and space to general thoracic surgery; (3) providing designated general thoracic surgery rotations on which the resident could focus his undivided attention on this subject; (4) development of areas of expertise in general thoracic surgery (e.g., esophageal surgery, lung transplantation) to attract increased case material; and (5) encouraging research and clinical innovation in general thoracic surgery. The committee further suggested that the American Board of Thoracic Surgery upgrade its requirements in general thoracic surgery; that the Residency Review Committee place greater importance on the performance of a program's graduates on the Board examination and more closely examine provisions made by each program for general thoracic surgical training; and that the Thoracic Surgery Directors Association emphasize to program directors that they are responsible for training deficiencies. The committee did not recommend a certificate of special competence in general thoracic surgery because of the potentially divisive effect on the overall specialty of thoracic surgery. In 1986, a follow-up questionnaire was sent by the Liaison Committee to training program directors to assess the impact, if any, of the 1984 report and recommendations. A total of 91 responses were received from III questionnaires sent (82%). The results were less than dramatic. Although 80% of programs had designated general thoracic surgery faculty and firstpriority operating room time for regular general thoracic surgery, in only 52% of programs were residents provided dedicated general thoracic surgery rotations without other clinical responsibilities. (An additional 43% of directors indicated that they intended to provide such training in the future, however). Sixty-nine percent (52/75) of the program directors did not believethat the committee's recommendations had had any influence on their training programs. Only 45% of program directors believed that their general thoracic surgery major case load had increased since 1982. The case load was the same in 51% of programs and less in 4%. Only 41% of programs had had an increase in esophageal surgery.
The Journal of Thoracic and Cardiovascular Surgery
(There was unfortunately no numerical documentation of actual operations performed to substantiate any of these impressions.) Eighty-two percent to 89% of directors believed that at least two of their last three graduates could teach their current residents how to perform their first pulmonary resection for lung cancer or their first coronary artery bypass or valve replacement for heart disease. But only 55% thought that their graduates could teach an esophageal resection for a mid-third carcinoma. With 20% of our training programs lacking general thoracic surgery faculty, only about 50% providing pure general thoracic surgery rotations, and nearly half of our graduating residents deemed by their program directors unsuited to train another to do an esophagectomy, one can only conclude that the fate of general thoracic surgery within the specialty of thoracic surgery still hangs in the balance! In their 1985 thoracic surgery manpower report, Loop and associates" indicated that surgeons older than 50 years of age perform more general thoracic surgery than younger surgeons. Among 126 diplomates of the American Board of Thoracic Surgery applying for recertification in 1985, only 28% indicated that they performed general thoracic surgery. In 1976, major general thoracic surgery procedures constituted 44% of all thoracic operations performed in this country; cardiac operations comprised 56%. In 1980, the ratio of general thoracic to cardiac operations was 35%:65% and by 1985, 33%:67%. It is clear that, just as general thoracic surgery has given way to cardiac surgery in most training programs, the same phenomenon has occurred in clinical practice. As indicated by Loop and associates,' "this skewed distribution toward cardiac surgery weakens general thoracic surgery, which has always been the cornerstone of our specialty." In 1987, the Liaison Committee, now chaired by Dr. Penfield Faber and consisting of Drs. John Benfield, George Magovern, James Mark, Martin McKneally, Mark Orringer, Richard Peters, and Watts Webb, considered additional means of enhancing general thoracic surgery residency training and the quality of care of general thoracic surgery patients. Their deliberations resulted in two documents: "Recommended Guidelines for General Thoracic Surgical Training Within a Cardiothoracic Training Program" (Appendix I) and "Recommended Environment for the Safe Practice of General Thoracic Surgery" (Appendix 11). Both of these documents were reviewed, discussed, and endorsed by the Council of the AATS in April 1988. The first of these is intended to serve as a guide for program directors in assessing the adequacy of their residency training in this area and to indicate areas of deficiency
Volume 97 Number 5 May 1989
Continuing dilemma of general thoracic surgery
that might be improved. These guidelines for general thoracic surgery training emphasize the desirability of at least 6 months of concentrated exposure to this area within the basic 2-year cardiothoracic residency; an operative experience providing a minimum number of indexed cases, as well as an outpatient exposure to the preoperativeevaluation and follow-up of general thoracic surgery patients; identifiable times set aside for the discussion and teaching of general thoracic surgery; and an appropriate conference schedule that fosters an appreciation of the interdisciplinary approach to general thoracic surgery patients. These guidelines are intended as recommendations and not a regimented set of requirements being imposed on thoracic surgery program directors. "Recommended Environment for the Safe Practice of General Thoracic Surgery" defines minimum standards deemed essential to provide appropriate quality care for patients undergoing elective general thoracic operations. It emphasizes the facilities, support services, and personnel that surgeons certified by the American Board of Thoracic Surgery should expectand demand of their hospitals before undertaking such operations. Since its inception in 1981, the Liaison Committee for Thoracic Surgery has focused its attention on the criteria for optimal residency training in general thoracic surgery and the safe practice of this specialty. However, the crisis in thoracic surgery-and we believe it should be characterized as such-is that the survival of general thoracic surgery within our specialty is threatened by the lack of well-trained, dedicated academic general thoracic surgery faculty in a significant number of training programs (at least 20% according to the 1986 survey of program directors). At an undetermined number of additional institutions, general thoracic surgery is performed and taught by older thoracic surgeons who have abdicated cardiac surgery for this "less stressful" field and lack a true interest or commitment to generate a new generation of general thoracic surgeons. We estimate that at this time there are at least 14 thoracic surgery programs with openings for general thoracic surgery faculty. We believe that, if unity within our specialty is to be maintained, thoracic surgery must move forward to ensure that the dramatic current deficit of academic general thoracic surgeons in our teaching progams is rectified within the next several years. It is only with good teachers of general thoracic surgery to serve as innovators and role models for our residents that more broadly and appropriately trained thoracic surgeons will emerge from our training programs, improve the practice of the specialty in this country, and perpetuate this
area of surgical expertise. How can we produce more academic general thoracic surgeons in the United States? Given the existing rotation structure of most of our residency training programs, it appears unlikely that sufficientexperience for a career as an academic general thoracic surgeon can be obtained in 2 years. Just as it has become commonplace for an individual intending to specialize in pediatric cardiac surgery to obtan an additional year of intensive training after residency, so too must the future academic general thoracic surgeon obtain more than the average exposure to the field offered in a 2-year residency. Residents seeking additional training in general thoracic surgery must obtain further clinical experience in large general thoracic surgery programs either abroad or in the United States. There are a small but recognized number of thoracic surgery programs in this country that provide abundant case material in general thoracic surgery and that, as the current leaders in general thoracic surgery, must become the source of the next generation of surgeons specializing in this field. It is the obligation of the program directors of these .select teaching programs to direct some of their residents each year into a career in general thoracic surgery. This can be achieved by providing an additional third year of exposure to laboratory and clinical general thoracic surgery. In programs with sufficient case material, the creation of such "fellowships" will not prevent the residents in the standard 2 years of training from obtaining adequate operating experience in general thoracic surgery. In fact, the value of an additional year of exposure to general thoracic surgery is not simply "doing more cases." Our U.S. trained residents, for example, who go to England to concentrate on pediatric cardiac surgery, gain little additional personal operating experience. Rather, the expertise they develop results from a complete immersion in an active pediatric cardiac surgery program and an exposure to the "gestalt" of this area of our specialty-the preoperative assessment, operative management, and postoperative care of these children. Similarly, over the course of a year, general thoracic surgery fellows can receive a comparable experience by an ongoing exposure to the complexities of this specialty, as well as related general thoracic surgery research, without "stealing" the basic clinical material needed to train thoracic surgery residents. Obviously, not every thoracic surgery training program will have the faculty, clinical material, or resources to develop such general thoracic surgery fellowships. But for the select few that can, now is the time to act. An additional important issue must be faced as the
65 I
The Journal of Thoracic and Cardiovascular
6 5 2 Orringer et af.
specialty of thoracic surgery grapples with its expressed commitment to retaining unity of the specialty and seeks to generate new leaders of general thoracic surgery from our academic training programs. There are not enough teachers of general thoracic surgery to perpetuate this field, and we are not going to be able to attract young thoracic surgery residents to careers in academic general thoracic surgery if they are offered lower base salaries than their peer co-faculty members beginning careers as cardiac surgeons within their departments or divisions. If we are truly committed to a unified specialty of thoracic surgery, there cannot be a "dual standard" of faculty compensation for young surgeons entering this field. An assistant professor of surgery doing general thoracic surgery should be offered a comparable salary to that paid an assistant professor of surgery doing cardiac surgery. They should both be members of the same department or division, and each has his value to the group as a whole. The potential income from an active general thoracic surgery practice is not inconsequential. Further, the best surgery residents for thoracic surgery training programs are not attracted to an institution only by the large volume of cardiac operations it performs, since many good training programs offer this advantage. The availability of an outstanding general thoracic surgery faculty and instruction is a tremendous asset to a training program that desires to attract residents who are seeking a broad, comprehensive cardiothoracic education. Program chairmen and directors should consider this matter of salary support carefully as they seek to recruit new general thoracic surgery faculty members. The current field of general thoracic surgery is far more exciting and challenging than the more mundane pulmonary resections and open lung biopsies that many consider representative of the field. Esophageal surgery for benign and malignant disease, more complex pulmonary resections (sleeve resection and segmentectomy), tracheal resection and reconstruction, chest wall resection and reconstruction, and lung transplantation provide a tremendous variety of clinical problems and challenges that should be attracting the brightest of thoracic surgery residents. A questionnaire from the Liaison Committee will soon be circulated to all thoracic surgery program directors to enable us to establish a registry of available general thoracic surgery faculty positions for residents who have completed selected training programs and have particular expertise and interest in a career in general thoracic surgery. The direction we must take to preserve the unity of the specialty of thoracic surgery is clear. The fate of general thoracic surgery is squarely in the hands of existing
Surgery
program directors who have the obligation to generate general thoracic surgeons through specialized training in this area and to create attractive faculty positions by providing financial incentives and sufficient resources to allow general thoracic surgery to again flourish. REFERENCES 1. Paulson DL. A time for assessment. J THoRAc CARDIOVASC SURG 1981;82:163-8. 2. Grillo HC, Benfield JR, Faber LP, et al. General thoracic surgery in cardiothoracic thoracic surgery: the search for balance. [Editorial]. J THoRAc CARDIOVASC SURG 1984; 88:321-3. 3. Grillo HC, Benfield JR, Faber LP, et al. General thoracic surgery in cardiothoracic thoracic surgery: the search for balance. [Editorial]. Ann Thorac Surg 1984;38:427-8. 4. Loop FD, Wilcox BR, Cunningham IN Jr, et al. Thoracic surgery manpower; the fourth manpower study of thoracic surgery-1985 report of the Ad Hoc Committee on Manpower of The American Association for Thoracic Surgery and the Society of Thoracic Surgeons. Ann Thorac Surg 1987;44:450-61.
Appendix I: Recommended guidelines for general thoracic surgical training within a cardiothoracic training program 1. Concentrated effort. All cardiothoracic residents should have a defined minimum period of concentration in general thoracic surgery, providing the resident the opportunity for focused attention on this element of his training without the conflict of clinical responsibility for cardiac surgical patients. This period should be at least 6 months in duration but may be substantially longer. 2. Operative/clinical experience. The operative experience should provide the following minimum number of indexed cases; 40 to 50 pulmonary resections 8 to 15 major esophageal operations 30 bronchoscopies 20 esophagoscopies In addition, the resident should be exposed to outpatient evaluation, the preoperative decision-making process, and follow-up of general thoracic surgical patients, whether in conference or on rounds. The resident should be exposed to the methodology and interpretation of-tests used to assess pulmonary and esophageal function (such as pulmonary spirometry, esophageal manometry, and pH reflux testing). 3. Teaching. Time should be set aside for faculty and residents to discuss and review the factual basis for the practice of general thoracic surgery. This should include but not be limited to the following topics: Thoracic surgical oncology Chest wall Esophagus Mediastinum Trachea, bronchus, and lung
Volume 97 Number 5 May 1989
Benign disorders of the esophagus Gastroesophageal reflux Neuromotor disorders Strictures Perforation Diverticulum Congenital malformations Tracheal injury and surgery Pulmonary infection and empyema Interstitial lung disease Chest wall deformities Thoracic trauma Pediatric thoracic surgery Thoracic critical care Mediastinal abnormalities and myasthenia Lung transplantation The format for communicating this information will vary at the discretion of the program director, on whom the responsibility for this training rests. 4. Conferences. A defined conference schedule, which is vital to teaching the resident the importance of an interdisciplinary approach to the general thoracic surgical patient and to fulfilling the educational goals defined in the preceding paragraphs, should include the following basic conferences: Combined pulmonary medicine/thoracic surgery Thoracic oncology conference Thoracic morbidity and mortality conference Thoracic surgery teaching conference The spirit of these recommendations is to provide guidelines for educating and training residents in general thoracic surgery, and not to impose a regimented set of requirements that might stifle flexibility and creativity in thoracic surgery training programs.
Appendix II: Recommended environment for the safe practice of general thoracic surgery The safe conduct of elective general thoracic surgery requires that the following facilities, support services, and
Continuing dilemma of general thoracic surgery
653
personnel be available to surgeons certified by the American Board of Thoracic Surgery: 1. Facilities Intensive care unit Recovery room Endoscopes-bronchoscopes and esophagoscopes (rigid and flexible); mediastinoscopes and esophageal dilators 2. Services (available 24 hours daily) Radiography (including fluoroscopy) Blood bank Respiratory therapy Arterial blood gases Angiography Nuclear medicine Echocardiography Pathology/cytopathology (including frozen section and rapid staining capabilities) 3. Support personnel Anesthesiologists---experienced in the use of tracheal dividers and thoracic anesthesia techniques Nurses-with training and experience in the postoperative care of general thoracic surgery patients Internal medicine consultants in the following specialities: Pulmonary medicine Cardiology Nephrology Infectious disease In the absence of the above facilities, support services, and personnel, it is recommended that elective major thoracotomies not be performed.
Number 5
May 1989
THORACIC AND CARDIOVASCULAR SURGERY The Journal
J
THORAC CARDIOVASC SURG
of
1989;97:649-53
Original Communications
The continuing dilemma of general thoracic surgery Where to now? Mark B. Orringer, MD, Ann Arbor, Mich., Joel D. Cooper, MD, St. Louis, Mo.. George Magovern, MD, Pittsburgh, Pa., James Mark, MD, Stanford, Calif., Martin McKneally, MD, Albany, N.Y, and Watts Webb, MD, New Orleans, La.
In
1981, in his presidential address to The American Association for Thoracic Surgery entitled "A Time for Assessment," Dr. Donald Paulson! expressed the growing concern of a number of leaders in this specialty about the status and future of general thoracic surgery. The tremendous technologic advances in cardiac surgery since the early 19508 and the impact of myocardial revascularization had relegated general thoracic surgery to a secondary role, and at many hospitals segments of this field had already been lost by default to surgeons with minimal thoracic training. In response to Dr. Paulson's .recommendations, the Council of the AATS later in 1981 appointed the Liaison Committee for Thoracic Surgery, charged with preserving "unity of the specialty through achievement of appropriate balance in each division of training, in the interest of competence in the delivery of quality health care." The original committee, chaired by Dr. Hermes Editor's Note: The authors of this manuscript constitute the Liaison Committee for Thoracic Surgery of The American Association for Thoracic Surgery; Chairman, Mark B. Orringer, MD. Received for publication Dec. 5, 1988. Accepted for publication Dec. 5, 1988.
C. Grillo, consisted of Drs. John Benfield, L. Penfield Faber, Donald G. Mulder, F. Griffith Pearson, Richard M. Peters, and Benson B. Roe. The committee developed a questionnaire that was used to survey thoracic surgery program directors and assess the relative emphasis being given to general thoracic surgery in resident education. The data from this survey formed the basis of a report to the Council of the AA TS in April 1983. On the assumption that an ideal thoracic surgery training program should provide each of its residents with 1DO major general thoracic and 100 major cardiac surgical procedures during his training, only 41% of the 85 teaching programs responding to the survey showed the appropriate balance; 14% were below standard and 45% were imbalanced. (Eleven programs did not respond.) Myocardial revascularization dominated residency training, and esophageal surgery was virtually absent in many programs. It was concluded that "general thoracic surgery is undersupported in (1) time and quality of instruction, (2) availability of case material, (3) assignment of case material to residents, (3) accessibility to beds and operating time, and (5) research funding." 649
6 50
Orringer et al.
A subsequent editorial appeared in both THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERy2 and The Annals of Thoracic Surgery? outlining the recommendations of the Liaison Committee, endorsed by the Council of the AATS, and intended to help remedy these deficiencies. Recommendations in principle were made to thoracic surgery program directors with the intent of increasing the emphasis on general thoracic surgery in residency training. These included (1) identifying specific faculty members responsible for instruction in general thoracic surgery; (2) designating beds, operating time, and space to general thoracic surgery; (3) providing designated general thoracic surgery rotations on which the resident could focus his undivided attention on this subject; (4) development of areas of expertise in general thoracic surgery (e.g., esophageal surgery, lung transplantation) to attract increased case material; and (5) encouraging research and clinical innovation in general thoracic surgery. The committee further suggested that the American Board of Thoracic Surgery upgrade its requirements in general thoracic surgery; that the Residency Review Committee place greater importance on the performance of a program's graduates on the Board examination and more closely examine provisions made by each program for general thoracic surgical training; and that the Thoracic Surgery Directors Association emphasize to program directors that they are responsible for training deficiencies. The committee did not recommend a certificate of special competence in general thoracic surgery because of the potentially divisive effect on the overall specialty of thoracic surgery. In 1986, a follow-up questionnaire was sent by the Liaison Committee to training program directors to assess the impact, if any, of the 1984 report and recommendations. A total of 91 responses were received from III questionnaires sent (82%). The results were less than dramatic. Although 80% of programs had designated general thoracic surgery faculty and firstpriority operating room time for regular general thoracic surgery, in only 52% of programs were residents provided dedicated general thoracic surgery rotations without other clinical responsibilities. (An additional 43% of directors indicated that they intended to provide such training in the future, however). Sixty-nine percent (52/75) of the program directors did not believethat the committee's recommendations had had any influence on their training programs. Only 45% of program directors believed that their general thoracic surgery major case load had increased since 1982. The case load was the same in 51% of programs and less in 4%. Only 41% of programs had had an increase in esophageal surgery.
The Journal of Thoracic and Cardiovascular Surgery
(There was unfortunately no numerical documentation of actual operations performed to substantiate any of these impressions.) Eighty-two percent to 89% of directors believed that at least two of their last three graduates could teach their current residents how to perform their first pulmonary resection for lung cancer or their first coronary artery bypass or valve replacement for heart disease. But only 55% thought that their graduates could teach an esophageal resection for a mid-third carcinoma. With 20% of our training programs lacking general thoracic surgery faculty, only about 50% providing pure general thoracic surgery rotations, and nearly half of our graduating residents deemed by their program directors unsuited to train another to do an esophagectomy, one can only conclude that the fate of general thoracic surgery within the specialty of thoracic surgery still hangs in the balance! In their 1985 thoracic surgery manpower report, Loop and associates" indicated that surgeons older than 50 years of age perform more general thoracic surgery than younger surgeons. Among 126 diplomates of the American Board of Thoracic Surgery applying for recertification in 1985, only 28% indicated that they performed general thoracic surgery. In 1976, major general thoracic surgery procedures constituted 44% of all thoracic operations performed in this country; cardiac operations comprised 56%. In 1980, the ratio of general thoracic to cardiac operations was 35%:65% and by 1985, 33%:67%. It is clear that, just as general thoracic surgery has given way to cardiac surgery in most training programs, the same phenomenon has occurred in clinical practice. As indicated by Loop and associates,' "this skewed distribution toward cardiac surgery weakens general thoracic surgery, which has always been the cornerstone of our specialty." In 1987, the Liaison Committee, now chaired by Dr. Penfield Faber and consisting of Drs. John Benfield, George Magovern, James Mark, Martin McKneally, Mark Orringer, Richard Peters, and Watts Webb, considered additional means of enhancing general thoracic surgery residency training and the quality of care of general thoracic surgery patients. Their deliberations resulted in two documents: "Recommended Guidelines for General Thoracic Surgical Training Within a Cardiothoracic Training Program" (Appendix I) and "Recommended Environment for the Safe Practice of General Thoracic Surgery" (Appendix 11). Both of these documents were reviewed, discussed, and endorsed by the Council of the AATS in April 1988. The first of these is intended to serve as a guide for program directors in assessing the adequacy of their residency training in this area and to indicate areas of deficiency
Volume 97 Number 5 May 1989
Continuing dilemma of general thoracic surgery
that might be improved. These guidelines for general thoracic surgery training emphasize the desirability of at least 6 months of concentrated exposure to this area within the basic 2-year cardiothoracic residency; an operative experience providing a minimum number of indexed cases, as well as an outpatient exposure to the preoperativeevaluation and follow-up of general thoracic surgery patients; identifiable times set aside for the discussion and teaching of general thoracic surgery; and an appropriate conference schedule that fosters an appreciation of the interdisciplinary approach to general thoracic surgery patients. These guidelines are intended as recommendations and not a regimented set of requirements being imposed on thoracic surgery program directors. "Recommended Environment for the Safe Practice of General Thoracic Surgery" defines minimum standards deemed essential to provide appropriate quality care for patients undergoing elective general thoracic operations. It emphasizes the facilities, support services, and personnel that surgeons certified by the American Board of Thoracic Surgery should expectand demand of their hospitals before undertaking such operations. Since its inception in 1981, the Liaison Committee for Thoracic Surgery has focused its attention on the criteria for optimal residency training in general thoracic surgery and the safe practice of this specialty. However, the crisis in thoracic surgery-and we believe it should be characterized as such-is that the survival of general thoracic surgery within our specialty is threatened by the lack of well-trained, dedicated academic general thoracic surgery faculty in a significant number of training programs (at least 20% according to the 1986 survey of program directors). At an undetermined number of additional institutions, general thoracic surgery is performed and taught by older thoracic surgeons who have abdicated cardiac surgery for this "less stressful" field and lack a true interest or commitment to generate a new generation of general thoracic surgeons. We estimate that at this time there are at least 14 thoracic surgery programs with openings for general thoracic surgery faculty. We believe that, if unity within our specialty is to be maintained, thoracic surgery must move forward to ensure that the dramatic current deficit of academic general thoracic surgeons in our teaching progams is rectified within the next several years. It is only with good teachers of general thoracic surgery to serve as innovators and role models for our residents that more broadly and appropriately trained thoracic surgeons will emerge from our training programs, improve the practice of the specialty in this country, and perpetuate this
area of surgical expertise. How can we produce more academic general thoracic surgeons in the United States? Given the existing rotation structure of most of our residency training programs, it appears unlikely that sufficientexperience for a career as an academic general thoracic surgeon can be obtained in 2 years. Just as it has become commonplace for an individual intending to specialize in pediatric cardiac surgery to obtan an additional year of intensive training after residency, so too must the future academic general thoracic surgeon obtain more than the average exposure to the field offered in a 2-year residency. Residents seeking additional training in general thoracic surgery must obtain further clinical experience in large general thoracic surgery programs either abroad or in the United States. There are a small but recognized number of thoracic surgery programs in this country that provide abundant case material in general thoracic surgery and that, as the current leaders in general thoracic surgery, must become the source of the next generation of surgeons specializing in this field. It is the obligation of the program directors of these .select teaching programs to direct some of their residents each year into a career in general thoracic surgery. This can be achieved by providing an additional third year of exposure to laboratory and clinical general thoracic surgery. In programs with sufficient case material, the creation of such "fellowships" will not prevent the residents in the standard 2 years of training from obtaining adequate operating experience in general thoracic surgery. In fact, the value of an additional year of exposure to general thoracic surgery is not simply "doing more cases." Our U.S. trained residents, for example, who go to England to concentrate on pediatric cardiac surgery, gain little additional personal operating experience. Rather, the expertise they develop results from a complete immersion in an active pediatric cardiac surgery program and an exposure to the "gestalt" of this area of our specialty-the preoperative assessment, operative management, and postoperative care of these children. Similarly, over the course of a year, general thoracic surgery fellows can receive a comparable experience by an ongoing exposure to the complexities of this specialty, as well as related general thoracic surgery research, without "stealing" the basic clinical material needed to train thoracic surgery residents. Obviously, not every thoracic surgery training program will have the faculty, clinical material, or resources to develop such general thoracic surgery fellowships. But for the select few that can, now is the time to act. An additional important issue must be faced as the
65 I
The Journal of Thoracic and Cardiovascular
6 5 2 Orringer et af.
specialty of thoracic surgery grapples with its expressed commitment to retaining unity of the specialty and seeks to generate new leaders of general thoracic surgery from our academic training programs. There are not enough teachers of general thoracic surgery to perpetuate this field, and we are not going to be able to attract young thoracic surgery residents to careers in academic general thoracic surgery if they are offered lower base salaries than their peer co-faculty members beginning careers as cardiac surgeons within their departments or divisions. If we are truly committed to a unified specialty of thoracic surgery, there cannot be a "dual standard" of faculty compensation for young surgeons entering this field. An assistant professor of surgery doing general thoracic surgery should be offered a comparable salary to that paid an assistant professor of surgery doing cardiac surgery. They should both be members of the same department or division, and each has his value to the group as a whole. The potential income from an active general thoracic surgery practice is not inconsequential. Further, the best surgery residents for thoracic surgery training programs are not attracted to an institution only by the large volume of cardiac operations it performs, since many good training programs offer this advantage. The availability of an outstanding general thoracic surgery faculty and instruction is a tremendous asset to a training program that desires to attract residents who are seeking a broad, comprehensive cardiothoracic education. Program chairmen and directors should consider this matter of salary support carefully as they seek to recruit new general thoracic surgery faculty members. The current field of general thoracic surgery is far more exciting and challenging than the more mundane pulmonary resections and open lung biopsies that many consider representative of the field. Esophageal surgery for benign and malignant disease, more complex pulmonary resections (sleeve resection and segmentectomy), tracheal resection and reconstruction, chest wall resection and reconstruction, and lung transplantation provide a tremendous variety of clinical problems and challenges that should be attracting the brightest of thoracic surgery residents. A questionnaire from the Liaison Committee will soon be circulated to all thoracic surgery program directors to enable us to establish a registry of available general thoracic surgery faculty positions for residents who have completed selected training programs and have particular expertise and interest in a career in general thoracic surgery. The direction we must take to preserve the unity of the specialty of thoracic surgery is clear. The fate of general thoracic surgery is squarely in the hands of existing
Surgery
program directors who have the obligation to generate general thoracic surgeons through specialized training in this area and to create attractive faculty positions by providing financial incentives and sufficient resources to allow general thoracic surgery to again flourish. REFERENCES 1. Paulson DL. A time for assessment. J THoRAc CARDIOVASC SURG 1981;82:163-8. 2. Grillo HC, Benfield JR, Faber LP, et al. General thoracic surgery in cardiothoracic thoracic surgery: the search for balance. [Editorial]. J THoRAc CARDIOVASC SURG 1984; 88:321-3. 3. Grillo HC, Benfield JR, Faber LP, et al. General thoracic surgery in cardiothoracic thoracic surgery: the search for balance. [Editorial]. Ann Thorac Surg 1984;38:427-8. 4. Loop FD, Wilcox BR, Cunningham IN Jr, et al. Thoracic surgery manpower; the fourth manpower study of thoracic surgery-1985 report of the Ad Hoc Committee on Manpower of The American Association for Thoracic Surgery and the Society of Thoracic Surgeons. Ann Thorac Surg 1987;44:450-61.
Appendix I: Recommended guidelines for general thoracic surgical training within a cardiothoracic training program 1. Concentrated effort. All cardiothoracic residents should have a defined minimum period of concentration in general thoracic surgery, providing the resident the opportunity for focused attention on this element of his training without the conflict of clinical responsibility for cardiac surgical patients. This period should be at least 6 months in duration but may be substantially longer. 2. Operative/clinical experience. The operative experience should provide the following minimum number of indexed cases; 40 to 50 pulmonary resections 8 to 15 major esophageal operations 30 bronchoscopies 20 esophagoscopies In addition, the resident should be exposed to outpatient evaluation, the preoperative decision-making process, and follow-up of general thoracic surgical patients, whether in conference or on rounds. The resident should be exposed to the methodology and interpretation of-tests used to assess pulmonary and esophageal function (such as pulmonary spirometry, esophageal manometry, and pH reflux testing). 3. Teaching. Time should be set aside for faculty and residents to discuss and review the factual basis for the practice of general thoracic surgery. This should include but not be limited to the following topics: Thoracic surgical oncology Chest wall Esophagus Mediastinum Trachea, bronchus, and lung
Volume 97 Number 5 May 1989
Benign disorders of the esophagus Gastroesophageal reflux Neuromotor disorders Strictures Perforation Diverticulum Congenital malformations Tracheal injury and surgery Pulmonary infection and empyema Interstitial lung disease Chest wall deformities Thoracic trauma Pediatric thoracic surgery Thoracic critical care Mediastinal abnormalities and myasthenia Lung transplantation The format for communicating this information will vary at the discretion of the program director, on whom the responsibility for this training rests. 4. Conferences. A defined conference schedule, which is vital to teaching the resident the importance of an interdisciplinary approach to the general thoracic surgical patient and to fulfilling the educational goals defined in the preceding paragraphs, should include the following basic conferences: Combined pulmonary medicine/thoracic surgery Thoracic oncology conference Thoracic morbidity and mortality conference Thoracic surgery teaching conference The spirit of these recommendations is to provide guidelines for educating and training residents in general thoracic surgery, and not to impose a regimented set of requirements that might stifle flexibility and creativity in thoracic surgery training programs.
Appendix II: Recommended environment for the safe practice of general thoracic surgery The safe conduct of elective general thoracic surgery requires that the following facilities, support services, and
Continuing dilemma of general thoracic surgery
653
personnel be available to surgeons certified by the American Board of Thoracic Surgery: 1. Facilities Intensive care unit Recovery room Endoscopes-bronchoscopes and esophagoscopes (rigid and flexible); mediastinoscopes and esophageal dilators 2. Services (available 24 hours daily) Radiography (including fluoroscopy) Blood bank Respiratory therapy Arterial blood gases Angiography Nuclear medicine Echocardiography Pathology/cytopathology (including frozen section and rapid staining capabilities) 3. Support personnel Anesthesiologists---experienced in the use of tracheal dividers and thoracic anesthesia techniques Nurses-with training and experience in the postoperative care of general thoracic surgery patients Internal medicine consultants in the following specialities: Pulmonary medicine Cardiology Nephrology Infectious disease In the absence of the above facilities, support services, and personnel, it is recommended that elective major thoracotomies not be performed.