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The Winds of Change
EDITORIAL
The Winds of Change
S
weeping through the academic world, the winds of change are forcing both students and teachers to reexamine the educational system in all its aspects. Medical education is being subjected to the same intense scrutiny, badly needed changes in the medical curriculum finally are being carried out in many schools. T h e process of becoming a physician, particularly a specialist, is too long, too rigid, too compartmented. Are the present laboriously developed criteria for training a thoracic surgeon so ideal that they should not be questioned? Is the requirement of four years of general surgery followed by two years of thoracic surgery the best way to train a thoracic surgeon? T h e Society of Thoracic Surgeons, since its beginnings, has been deeply interested in the training needed by thoracic surgeons. Drs. Byron and Chamberlain, two of our most respected members who died recently, with others, had published in T h e Annals several editorials about thoracic training. T h e American Association for Thoracic Surgery has shared this interest also; more than 30 years ago it held a symposium at one of its meetings in which many of our present concepts of thoracic training were proposed, and the same questions which continue to concern us were raised. T h e Board of Thoracic Surgery has striven to improve the quality of training programs in thoracic surgery, and its members have continued to examine critically the presently accepted “ideals” for such training. As a member of the Board of Thoracic Surgery I have been deeply impressed by the complete dedication of this group to the goal of defining what constitutes good training. (Obviously, any statements made in this editorial reflect only my personal views.) In their very effort to improve the quality of thoracic training the members of the Board of Thoracic Surgery have been forced to establish relatively rigid standards that may not have kept pace with this rapidly advancing field. How does one reconcile the need to shorten the time devoted to medical education with the increasing complexity of the material with which the thoracic surgeon must be familiar? There seems little quesVOL.
6,
NO.
4, OCTOBER, 1968
413
Editorial
tion that the surgeon, whatever his specialty, needs a basic knowledge of surgery and that this can be acquired best by training in general surgery. Thoracic surgery has been more closely related to general surgery than any of the other surgical specialties, and is the only specialty which demands that the trainee be certified by the American Board of Surgery before he can become certified by the Board of Thoracic Surgery. Other specialties are now requesting that their trainees have longer exposure to general surgery before starting specialty training. There is very real concern that not enough general surgery is available to meet these increasing demands. Since the addition of cardiovascular surgery to most thoracic programs and the marked reduction of tuberculosis cases as a source of training material, the environment in which thoracic training occurs in most centers has changed almost completely. A young thoracic surgeon must now learn the complexities of cardiovascular physiology, the intricacies of cardiac diagnostic procedures, and the techniques of whole-body perfusion in addition to the traditional concepts of thoracic surgery. How many men competent in cardiac surgery should be trained? The thoracic surgeon who plans to practice in the community may not wish to become involved in open-heart surgery and may feel that this additional training is unnecessary. Yet, as the necessary supporting services become more widely available, surgery of this kind is successfully being carried on outside major medical centers with increasing frequency. T o many of us involved in training thoracic surgeons, the present two-year period seems inadequate. True, improved teaching techniques and modifications of the apprentice system so characteristic of most surgical programs will make our efforts more effective, but these changes will still fail to provide the young surgeon with the knowledge and experience he needs. The Millis report [l] recognizes the problems in graduate medical education and urges that teaching hospitals experiment with new programs in specialty training. While the medical profession may not accept the report in its entirety, there is need for innovation and experimentation in our training programs if we are to maintain the same standards of excellence which have made American surgery outstanding. Such an experimental program might consist of three years of basic surgical training after graduation from medical school, followed by three years of training in thoracic surgery. The additional year of thoracic surgery should allow the trainee to become proficient in all aspects of thoracic surgery, and it should also provide him the opportunity to assume responsibility for the surgical care and treatment of complicated cardiovascular problems, an opportunity not offered in most two-year programs. At the present time a two-year thoracic training program 414
T H E ANNALS OF THORACIC SURGERY
Editorial
usually does not permit a period for investigation if the trainee has such an interest. A third year of training would provide this time. Any deficiencies in the acquisition of surgical technique and the development of surgical maturity from the shortened exposure to general surgery should be more than made up by the increased experience in thoracic surgery. It will be necessary for both the American Board of Surgery and the Board of Thoracic Surgery to recognize the experimental programs. Satisfactory solutions to these problems can be found, and the quality of thoracic training will then continue to parallel the phenomenal growth of thoracic surgery in the last two decades. T h e winds of change are not necessarily ill winds.
HERBERT SLOAN, M.D. Ann Arbor REFERENCE 1. Millis, J. S. (Chairman). Report of the Citizens Commission on Graduate Medical Education, 1966. Commissioned and published by the American Medical Association.
VOL.
6,
NO.
4, OCTOBER, 1968
415
The Winds of Change
S
weeping through the academic world, the winds of change are forcing both students and teachers to reexamine the educational system in all its aspects. Medical education is being subjected to the same intense scrutiny, badly needed changes in the medical curriculum finally are being carried out in many schools. T h e process of becoming a physician, particularly a specialist, is too long, too rigid, too compartmented. Are the present laboriously developed criteria for training a thoracic surgeon so ideal that they should not be questioned? Is the requirement of four years of general surgery followed by two years of thoracic surgery the best way to train a thoracic surgeon? T h e Society of Thoracic Surgeons, since its beginnings, has been deeply interested in the training needed by thoracic surgeons. Drs. Byron and Chamberlain, two of our most respected members who died recently, with others, had published in T h e Annals several editorials about thoracic training. T h e American Association for Thoracic Surgery has shared this interest also; more than 30 years ago it held a symposium at one of its meetings in which many of our present concepts of thoracic training were proposed, and the same questions which continue to concern us were raised. T h e Board of Thoracic Surgery has striven to improve the quality of training programs in thoracic surgery, and its members have continued to examine critically the presently accepted “ideals” for such training. As a member of the Board of Thoracic Surgery I have been deeply impressed by the complete dedication of this group to the goal of defining what constitutes good training. (Obviously, any statements made in this editorial reflect only my personal views.) In their very effort to improve the quality of thoracic training the members of the Board of Thoracic Surgery have been forced to establish relatively rigid standards that may not have kept pace with this rapidly advancing field. How does one reconcile the need to shorten the time devoted to medical education with the increasing complexity of the material with which the thoracic surgeon must be familiar? There seems little quesVOL.
6,
NO.
4, OCTOBER, 1968
413
Editorial
tion that the surgeon, whatever his specialty, needs a basic knowledge of surgery and that this can be acquired best by training in general surgery. Thoracic surgery has been more closely related to general surgery than any of the other surgical specialties, and is the only specialty which demands that the trainee be certified by the American Board of Surgery before he can become certified by the Board of Thoracic Surgery. Other specialties are now requesting that their trainees have longer exposure to general surgery before starting specialty training. There is very real concern that not enough general surgery is available to meet these increasing demands. Since the addition of cardiovascular surgery to most thoracic programs and the marked reduction of tuberculosis cases as a source of training material, the environment in which thoracic training occurs in most centers has changed almost completely. A young thoracic surgeon must now learn the complexities of cardiovascular physiology, the intricacies of cardiac diagnostic procedures, and the techniques of whole-body perfusion in addition to the traditional concepts of thoracic surgery. How many men competent in cardiac surgery should be trained? The thoracic surgeon who plans to practice in the community may not wish to become involved in open-heart surgery and may feel that this additional training is unnecessary. Yet, as the necessary supporting services become more widely available, surgery of this kind is successfully being carried on outside major medical centers with increasing frequency. T o many of us involved in training thoracic surgeons, the present two-year period seems inadequate. True, improved teaching techniques and modifications of the apprentice system so characteristic of most surgical programs will make our efforts more effective, but these changes will still fail to provide the young surgeon with the knowledge and experience he needs. The Millis report [l] recognizes the problems in graduate medical education and urges that teaching hospitals experiment with new programs in specialty training. While the medical profession may not accept the report in its entirety, there is need for innovation and experimentation in our training programs if we are to maintain the same standards of excellence which have made American surgery outstanding. Such an experimental program might consist of three years of basic surgical training after graduation from medical school, followed by three years of training in thoracic surgery. The additional year of thoracic surgery should allow the trainee to become proficient in all aspects of thoracic surgery, and it should also provide him the opportunity to assume responsibility for the surgical care and treatment of complicated cardiovascular problems, an opportunity not offered in most two-year programs. At the present time a two-year thoracic training program 414
T H E ANNALS OF THORACIC SURGERY
Editorial
usually does not permit a period for investigation if the trainee has such an interest. A third year of training would provide this time. Any deficiencies in the acquisition of surgical technique and the development of surgical maturity from the shortened exposure to general surgery should be more than made up by the increased experience in thoracic surgery. It will be necessary for both the American Board of Surgery and the Board of Thoracic Surgery to recognize the experimental programs. Satisfactory solutions to these problems can be found, and the quality of thoracic training will then continue to parallel the phenomenal growth of thoracic surgery in the last two decades. T h e winds of change are not necessarily ill winds.
HERBERT SLOAN, M.D. Ann Arbor REFERENCE 1. Millis, J. S. (Chairman). Report of the Citizens Commission on Graduate Medical Education, 1966. Commissioned and published by the American Medical Association.
VOL.
6,
NO.
4, OCTOBER, 1968
415