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The specialty of thoracic surgery has enjoyed spectacular growth and development during the past half century. Many advances in the field led to its preeminence among the surgical specialties, and surgical trainees from around the world were attracted to a limited number of training programs. From the late 1970s through the 1990s, there was growth in both the number of training programs and the number of surgeons entering the specialty. That growth, however, has turned into a steady decline during the past decade. There has been a decline in both applicants and programs throughout the United States. Perceptions of the specialty have changed among medical students and general surgical residents, which has led to a relative surplus of positions in comparison with the number of applicants nationwide.1,2 This has occurred in the same setting that fostered expansion of the specialty: a growing and aging population, with increasing needs for the services of thoracic surgeons. Coincident with this unmet demand is an accelerating rate of retirement among experienced cardiothoracic surgeons, due to an aging workforce. These factors have created a trend in which the specialty is on course to have the largest negative percentage change in active physicians of any specialty over the decade to come (Fig. 1).
A number of recent changes at various levels throughout the specialty have renewed our emphasis on thoracic surgical education, and that emphasis in turn has led to our rethinking the content and delivery of the chief components of thoracic training. This rethinking has certainly been a work in progress because there are now approximately 5 pathways to achieve board certification in thoracic surgery—more than any other specialty has at the present time. Pathways include the full prerequisite training in general surgery, followed by training in thoracic surgery that is distributed roughly 50–50 between 2- and 3-year residencies; a combined general surgery/thoracic surgery route; a vascular surgery/thoracic surgery route; and an Integrated 6-year thoracic surgery pathway. These muddled pathways appear to have yielded poor results both in educational quality (lower board passage rates) and in the number of trainees produced (fewer graduates). Moreover, the match trends of the National Resident Matching Program show that the current educational product is not in demand (Fig. 2).
As a consequence of renewed interest in surgical education, the leadership in thoracic surgery has focused its resources on the issue at hand—how to train the best thoracic surgeons for tomorrow's healthcare system. How do we, as surgeon educators, redesign our approach to creating and delivering educational content germane to our specialty? The balance between a strong foundation in general surgery and the need to attain specialized thoracic surgical skills has shifted, to place greater focus on cardiothoracic surgery knowledge. In addition, the measurable mastery of skills is seen as more desirable than spending a specified period of time on a particular rotation. Increased exposure to the components of specialties that intersect thoracic surgery—such as heart-failure cardiology, pulmonary medicine, and advanced thoracic imaging—will be of paramount importance to our educational enterprise. Finally, we will need to follow the example of aviation, space exploration, and the military by incorporating simulation strategically into our teaching methods and practices.3 Consider, too, all of the challenging outside factors that necessarily affect our educational endeavors: greater oversight by accrediting organizations, increasing institutional and national regulations, the economic realities of our healthcare system, and the demands for greater public disclosure and transparency.4,5
Although time alone is a poor measure of competence, an initial 6-year Integrated pathway of training, beginning directly after graduation from medical school, may provide the matrix for an initial redesign of thoracic surgical education. There will need to be a firm foundation in general surgical principles and surgical critical care, together with a thorough understanding of the pathophysiology of cardiothoracic diseases. This will have to be combined with the graduated introduction of simulated operating-room and intensive-care experiences, while instruction also proceeds in the relevant areas of such related specialties as pulmonary medicine, cardiology, and imaging. Thoracic education can then culminate with an emphasis on such areas as transplantation, minimally invasive surgery, and congenital heart surgery. It is clear that the status quo is no longer acceptable. Although we have not yet settled upon final content in terms of skills, knowledge, or chronological pathway, our specialty is engaged in an appropriate educational redesign. This will ensure that future thoracic surgeons are better prepared for tomorrow's patients.
Address for reprints: V. Seenu Reddy, MD, MBA, Department of Thoracic Surgery, University of Texas Health Science Center–San Antonio, 7703 Floyd Curl Dr., MC 7841, San Antonio, TX 78229
Presented at the Joint Session of the Denton A. Cooley Cardiovascular Surgical Society and the Michael E. DeBakey International Surgical Society; Austin, Texas, 10–13 June 2010