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Ann Thorac Surg 1998;65:901-902
© 1998 The Society of Thoracic Surgeons
a Ingalls Memorial Hospital, Harvey, Illinois, USA
Address reprint requests to Dr Replogle, Ingalls Memorial Hospital, One Ingalls Dr, Suite W536, Harvey, IL 60426
This editorial was written by Dr Robert L. Replogle at the request of Mr Frank Tamru, publisher of the Asian Cardiovascular & Thoracic Annals, and was published in the December 1997 issue of that journal. It is such a fine exposition of the goals espoused by Dr Replogle during his year as President of The Society of Thoracic Surgeons that we requested permission to reproduce the article for readers of The Annals of Thoracic Surgery.
The Editor
Progress in transportation and communication during the past 200 years have led poets, songwriters, and politicians to muse on how small our world really is. When overseas travel involved a sailing ship, personal communication involved months of travel. The advent of motor driven ships was a startling breakthrough, it meant that the traveler could cross the Atlantic in 5 days, and only 14 days to the Far East! Along came the wireless radio, the telegraph and the telephone, and suddenly folks in China were directly connected to their friends in Denmark in seconds. Then came television, and in the comfort of our home we could actually see events in all the countries of the world, become familiar with the people and their everyday lives, and recognize that we all have similar ambitions, hopes, concerns; that the people, if asked, want peace, prosperity, and friendship with one another. This set the stage for the new revolution.
The origins of the Internet came from military efforts to maintain national communications in the United States in case of nuclear attack. The development of a computer based communication system, which was so diffuse that it would be impossible to wipe out with localized destruction, was the handiwork of a genius, and it led to civilian uses which turned out to be much greater than the military ones. As a matter of fact, this is one of the greatest spin-offs of military to civilian usage; the other is the treatment of shock and trauma.
While the fax was an interesting intermediate step, very quickly e-mail has become the communication device of choice. The beginning of the Internet was slow only for a few months, because almost simultaneous with the efforts of a whole new generation of creative people who wanted to display their efforts on this modality, technology roared ahead and provided them, and everyone else, with the tools to exploit fully the possibilities of this new technology.
What does this have to do with cardiothoracic surgery and globalization? Several implications are obvious. The transfer of information by books and journals was once done by sailing vessel, then by steamer (still done this way in many instances) and finally, if cost was no object, by plane. Sending the Asian Cardiovascular & Thoracic Annals, or The Annals of Thoracic Surgery by snail mail meant that the journal reached the reader in 2 or 3 months, at a transportation cost more than the cost of the journal itself. The Internet can provide virtually instant transfer of the journal articles, at low cost, since there are much lower transportation expenses. There will be interactive journal articles, video articles, discussion groups, and much, much more than we currently have. Using Medline, everyone in the world will have instant access to the great medical libraries of the world.
However, the most important, and far reaching effect of the Internet on cardiothoracic surgery will be globalization of our specialty. We surgeons have been slow to participate in what has become the economic story of the decade. The ability of some countries to build up capital (money) resources meant that they could be the leaders in the manufacturing process simply because they had the money to build the factories. As competition developed, this capital (and factories) went to more profitable areas of the world. Soon money was being distributed all over the world; the multinational corporation was born. One thing became very clear, wherever products were manufactured, the quality of the product had to be maintained at similar level if the product was to be accepted by a discerning public. There is no special consideration given because of the source of the goods. A country could not take the position that it was underdeveloped and therefore privileged to put out an inferior product. To use a sports analogy, when the bar for the high jump is set at the Olympic Games, it is set at the same height for everyone. There are no special considerations given to compensate for the particular background of each athlete.
I foresee the day when there will be a world standard for cardiothoracic surgery, and the tools to do this are now at hand. In the USA, the educational system for surgery evolved from the scheme devised by Halsted, with graded responsibility and senior surgeon teaching junior surgeon. This method of training was refined by adding the final examination by the American Board of Thoracic Surgery. More recently, the curriculum required for training, and the capacity of teaching institutions to provide an excellent environment for training is regularly examined by the Residency Review Committee for Thoracic Surgery and in those teaching hospitals that do not meet these standards, the residency program is removed. There is no good reason why standards cannot be worldwide. They do not have to be USA standards; there can be an international committee to set standards both for training as well as for examination. Some thoracic diseases are more important in some countries than in others, and the thrust of the curriculum should reflect that. However, the type and content of basic cardiothoracic surgery training must have some consistency if we are truly going to have worldwide recognition of training and achievement in our profession. The Internet provides a beginning for this revolution, whereby a surgeon trained in China will have similar background and experience in cardiothoracic surgery to one trained in Germany.
How will this come about? By international exchange of information. The American Board of Thoracic Surgery has a page on the Web, and has placed there the requirements that all residents must meet before they can undergo examination. The training directors in thoracic surgery have established a site, and have placed there the curriculum required for the resident to master, as well as many other important and pertinent communication. The residents themselves have established a fantastic page, filled with the information of a scientific and cultural nature that they feel is important, including the logs that they are required to fill out to establish for the record their surgical experience. This was done through the efforts of Dr. John Liddicoat and Dr. John Doty, Johns Hopkins residents in cardiovascular surgery, with the enthusiastic, fatherly support of Dr. Don Doty and the benefit of a handsome educational grant from Medtronic.
The Society of Thoracic Surgeons (STS) perceived, early, the need for a database to permit the profession to determine the quality of cardiothoracic surgery. This too has been evolving, the most recent count shows that over one million coronary bypass patients have been incorporated into the database. While it is as yet far from perfect, it is the best that we have in this country, and the federal government is considering designating it to be the basis for the official database, pending some changes, largely to incorporate cardiology into the new database. In the future, PTCA, CABG, and other treatments can be compared much more easily, using the same database. The STS has been working with the Society of Cardiothoracic Surgeons of Great Britain and Ireland to develop a common database, and plans are underway to cooperate with the European Association of Cardio-thoracic Surgery to develop a common database between Europe and the USA. One day, I see a worldwide database where the efforts of cardiothoracic surgeons around the world can be compared. (CTSNet—www.ctsnet.org—is quickly moving towards being the Web site in which all cardiothoracic surgeons worldwide will want to, or need to, participate.) At that time, there will not be any exceptions made; those surgeons who meet world standards will be accepted into the global community of surgeons, and those who do not may have to find other employment. Whether you like it or not, this is the future.
How will this work out? First, we need to continue visits among surgeons to get to know each other. The better you know your colleagues, the easier it is to work out common problems. There have been many intercontinental visits since the origin of cardiothoracic surgery, and they have become an important part of this fellowship of surgery. Second, there needs to be developed in each area of the world a regional association that will provide a home for the surgeons of that region, and will make it possible to identify those surgeons qualified by training and experience, to be accepted by all of the surgical community. In general, this means that not only is an association required, but also a journal, which is necessary to provide an intellectual basis for surgical scholarship. In Asia, the Asian Cardiovascular & Thoracic Annals admirably fills that requirement. It would be a real advance if the surgeons of Asia could form a new regional association, much as they have in Europe and the USA, for example the Asian Association of Cardiothoracic Surgeons.
We are at the stage in technology where we can have much greater interaction with one another by using the communication and educational power of the Internet, reducing the need for the time-wasting and expensive long distance travel. At the moment, this means that our colleagues all over the world need to become proficient enough to get on a computer, and get the information. Regional associations can help develop this expertise, just as the STS provides computer training at all its meetings for surgeons who are not yet competent on computers. Those surgeons who do not get involved in this flow of information will be left at the starting line, and will have a difficult time meeting the changing world standards. While language will be a temporary obstacle, very shortly translation packages will overcome this problem.
I recently returned from China. I was not surprised, but pleased by the quality of the surgery there, the intensity of the profession doing the best work possible, and the dedication of all involved in cardiothoracic surgery to provide for their patients the highest quality work. There are great surgeons all over the world, we should get to know them, wherever they may work, and together we should work toward a common goal, the best possible care provided for our friends, family, neighbors, as these are all our patients. The age of the worldwide community of cardiothoracic surgeons is here. Join in!
Footnotes
Reprinted with permission from the Asian Cardiovascular & Thoracic Annals 1997;5:191–2.
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