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Ann Thorac Surg 2000;69:1319-1320
© 2000 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
Address reprint requests to Dr Grillo, Department of Thoracic Surgery, Massachusetts General Hospital, Thoracic Surgical Unit/Warren 1101, 55 Fruit St, Boston, MA 02114
The Thoracic Comprehensive Curriculum Document promulgated by the Thoracic Surgery Directors Association provided a first attempt to define in detail the content of cardiothoracic surgical education. The goals were to guide instruction by faculty, learning by residents, and to provide a basis for program evaluation. This was a thoughtful step in the evolution of residency programs from the "pot luck" approach of teaching the resident by precept and experience based on whatever was the clinical mass and distribution of patients in a given unit. The history is long of the evolution of training requirements from total number of cases performed to insistence upon breadth of experience across the spectrum of cardiac and general thoracic surgery. This matter became particularly acute a few decades ago when the dominance of thoracic surgery by the burgeoning of adult cardiac surgery was so overwhelming that general thoracic surgical education became alarmingly attenuated. The rather primitive mechanism of case type quotas was instituted by the Board as necessary to begin some restoration of educational balance in residency programs. Thus, tension inherent in the broadly defined specialty of thoracic surgery among its components of general thoracic surgery, adult cardiac surgery, and congenital cardiac surgery militated in favor of a broadly based education, bringing with the technical knowledge varied physiology and pathology. I use the word tension to indicate forces at work rather than in an adversarial sense.
A further tension in designing a residency program arises between a desire on one hand to codify each detail of content versus the take-it-as-it-comes approach originally used. Cardiothoracic surgical training programs vary greatly in content depending on the particular history of an institution, the interests of its staff, its flow of patients, and other factors determined outside the educational domain. The efforts of the Board of Thoracic Surgery and of the Residency Review Committee have been notable in bringing some conformity to these natural variations and in assuring that candidates for training receive a reasonably broad and preferably deep education in many aspects of cardiothoracic surgery. The goal of the Board is fundamentally to certify surgeons who will practice their specialty knowledgeably and safely. The goal, therefore, is a pragmatic one. The Thoracic Surgery Directors Association has moved on to a proper consideration of the total educational experience deemed appropriate for a thoracic surgeon.
The present survey has twin goals of measuring perceived adequacy of instruction in the Curriculum, which was outlined and, further, its relevance to individual practice [1]. Thus, it is a report of consumer satisfaction and opinion. "Relevance to practice" is a wholly pragmatic yardstick. It is, therefore, not surprising that the objectives most relevant to practice mirror the predominant adult cardiac surgical practices (65%) of those surveyed; 62% of "most relevant" items were related to adult cardiac surgery. By the same measure, the least relevant subjects, as might be expected, include congenital heart problems, transplantation, esophageal physiology, and tracheal surgery. Because each of these areas is likely to be managed to great extent by a relatively few surgeons, relevancy to practice scores were low overall.
A further fault line noted in the study was a difference in the sense of relevance to practice of the curriculum as seen by those in academic and in nonacademic institutions. What seems likely is that surgeons in academic institutions are more specialized even within their subspecialties of cardiac, thoracic, and congenital heart surgery, as is so often the case where special areas of interest are espoused by specific members of a faculty (eg, thoracic outlet syndrome). In addition, these institutions provide specialized facilities and strong support staff as for cardiopulmonary bypass. Hence, the individual surgeon may not strongly feel the need for profound knowledge and proficiency in each area insofar as day-to-day practice demands.
Opinions about perceived weaknesses in instruction were clearly in areas of nonoperative information: in cardiac, esophageal, pulmonary, and transplantation knowledge, diagnostic methods, and statistical assessment. The present study will be valuable if it stimulates program directors and faculties to emphasize teaching in these areas more fully. This is difficult to do given the extraordinarily heavy workload carried by cardiothoracic residents in their daily tasks of caring for their patients in and out of the operating room, properly their first obligations. Tension between service needs and educational needs has long been recognized as inherent in necessarily hospital-based learning. The ogre of "same-day surgery" also provides a real if oblique deflection of educational opportunities in diagnostic and functional appraisal of patients. We should not like to see "virtual" patient care replace the present pedagogical standard of direct patient care, but, as the authors suggest, supplemental technologies may become useful. In some weak areas, such as esophageal surgery, overall available experience can be enriched by faculty concentration and subspecialization to increase the critical mass. In some areas, such as rare congenital heart diseases and tracheal surgery, there simply are not enough patients to go around. It is heartening to note that the respondents recognized areas where their education was weakest despite the lack of "relevance" to their everyday practices.
In light of the responses to this survey and mindful of the time constraints of residency, the authors raise the question of whether programs should be tailored to the resident’s anticipated career goals. Although tracking is indeed offered in some programs and can be seen as a positive development, the basic maturation of the cardiothoracic resident should remain a broad educational process. For this, a broad-based program is mandatory, at least as long as we truly wish to produce credible cardiothoracic surgeons, surgeons with competence in the full range of the specialty as presently defined. This is the base on which the surgeon’s life-long educational progress will rest and this is what the residency program should have as a major goal. Narrowly directed technical training, even with a modicum of enlightenment on essential closely related areas, will prepare the student less well to contribute to or even manage the challenging advances that certainly lie ahead. The absolute need for breadth of training is far more than a matter of providing a cultural background in our specialty. In it lie the very seeds of real progress.
In 1946, Dr Edward D. Churchill recognized two categories of specialism [2]. The first he called specialization, the necessary acquirement of skill in application of already standardized techniques. The second he labeled concentration in the chosen field in which new techniques may be applied or principles discovered that may be applicable even beyond the field. Students, Churchill stated, should be encouraged to concentrate but not to specialize exclusively. He wrote, "The difference lies in the tendency of a technical specialist to exclude all other subjects from his interest and study. The concentrator seeks to maintain an active curiosity and interest concerning all techniques that might be useful in his area of concentration, and views his work in proper perspective with science as a whole. ...Specialism in the narrow technical sense can flourish only in a trade school of applied techniques."
A further very practical reason for breadth of training is the unpredictability of individual careers in the three closely related special areas of cardiothoracic surgery. In some programs, recruitment and tracking is such that the candidate rarely departs from his predestination, most often as a cardiac surgeon. It has been the experience of many directors that candidates exposed in depth to the full breadth of cardiothoracic surgery not infrequently change their original goals. This can be a change in academic versus private practice or in commitment to congenital heart surgery, general thoracic surgery, adult cardiac surgery, or combinations sometimes dictated by a specific job opportunity. I do not believe that there is anything negative about this. It is perfectly reasonable for the graduate to become familiar with the riches before him and eventually select that area or pattern that interests him most. This in no sense is a criticism of special "tracking" programs, but for the majority of residents, there is every reason to maintain breadth.
If one were to follow a logic of pragmatism, a good case could be made for dividing the field into three subspecialties with different prerequisites for each subdivision and very different programs of technical surgical training. Such steps should not be allowed to occur by misdirection. I do not believe many would wish to move deliberately in this ultimately stultifying direction. We do not want to push our specialty into a pattern of trade school organization rather than that of a learned profession. We should not consider sacrificing breadth of education in all aspects of cardiothoracic surgery for a narrow technical training in a single subdivision. Churchill cited Whitehead’s admonition that: "Necessary technical excellence can only be acquired by a training which is apt to damage those energies of mind which should direct the technical skill." We are obligated to impart the technical skills but we must not dull the "energies of mind" that will make forward steps. Serious thought must therefore be given to current proposals that would abbreviate the rounded education in surgery now required for admission to cardiothoracic residency. The present educational program has produced some of the finest cardiothoracic surgeons in the world. We must remind ourselves that we are educators in cardiothoracic surgery and not merely master craftsmen training apprentices in narrow skills. Our residency programs are programs of education in cardiothoracic surgery and related subjects even as we continue to teach craftsmanship. This is not a plea for immutability in cardiothoracic education but rather for making changes governed by clearly conceived educational purposes.
References
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