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Ann Thorac Surg 2004;78:2-8
© 2004 The Society of Thoracic Surgeons
a General Thoracic Surgery, The Emory Clinic, Emory University School of Medicine, Atlanta, Georgia, USA
* Address reprint requests to Dr Miller, General Thoracic Surgery, Emory University School of Medicine, 1365 Clifton Rd, NE, Building A–A2206, Atlanta, GA 30322, USA
e-mail: jmille6331{at}aol.com
Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003.
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Introduction |
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Harvey Bender stated that presidential addresses tend to be one of three types [1]: (1) The first type is a scientific paper based on an area of his or her special interests and one that frequently stresses clinical outcomes in the management of a disease process; (2) the second type is historical, one that reviews and documents important turning points in the development of the specialty and emphasizes the important roles played by previous leaders in the field; (3) the third type is philosophical, and I think mine best fits into that category.
I feel that we have to look at the preservation of the specialty of cardiothoracic surgery and the qualities that the complete cardiothoracic surgeon will need to learn and acquire as we move into the second millennium. Preservation of the specialty and pursuit of qualities of excellence in cardiothoracic surgery (CTS) are what will sustain not only the Southern Thoracic Surgical Association, but also our specialty as a whole.
In my opinion, the specialty has never been held in higher esteem by other specialties or by the public. In most institutions, the department or division of cardiothoracic surgery sets the standard that all of the other departments follow: in economics, local and national involvement, publications, and level of expertise. When I look at the 16 members of our section who are present at division meetings, I am amazed at the extraordinary collection of talent gathered under the leadership of Dr. Robert Guyton.
As I approached this address, my thoughts focused on two universal aspects of our specialty: One, the training of cardiothoracic surgery residents and two, the pursuit of qualities that will result in strengthening our specialty.
As we look at our role in training cardiothoracic surgery residents, we should remember precepts from our Hippocratic Oath: "I will look upon him who shall have taught me this Art even as one of my parents — I will impart this Art by precept, by lecture and by every mode of teaching— to disciples bound by covenant and oath, according to the law of medicine." [2].
Reflecting on our role as teacher, Dr. David Faxon, immediate past president of The American College of Cardiology, expressed it well: "In our profession we are sometimes called to be teachers and sometimes to be students. In some cases we have the answers that others seek; at other times we seek answers from those who may be more experienced and wiser than we. Each of us has faced pivotal moments in our lives and in our careers when we have sought answers, guidance, and inspiration from the same sources again and again, and have been provided with direction, to clarity and a renewed sense of purpose. These people assume the mantle of ‘Mentors’ for us and without them we may not have been able to achieve our loftiest goals and ideals" [3]. Faxon further stated, "I ask you to recall your own personal Mentors and how your lives would have been less fulfilling without them. I ask you, to whom do the students of today turn? From whom do they seek wisdom, guidance, and insight? Who teaches them patience, perseverance, and practice?" [3].
As Richard E. Clark in his Presidential Address to the Southern Thoracic Surgical Association so eloquently stated, "As we age singularly and collectively, we have forgotten the importance of the hero in our lives. Heroes are our beacons in the downpours and in the fog. Heroes enrich us and inspire us to persevere and help us feel that our lives are worthwhile" [4].
Such has been the presence of heroes in my life and training. The names Kirkland, Clagett, McGoon, Hatcher, and Guyton, have already been mentioned but there have also been others. Doctor Penfield Favor and Dr. Hal Urschel have helped me tremendously along the way. They have been beacons of light and have provided mentorship and friendship. For the collegiality and friendship of Dr. Peter Pairolero, Dr. William Baumgartner, Dr. Timothy Gardner, Dr. Fred Crawford, and Dr. Douglas Mathisen, I will always be grateful.
We as teachers must not only instruct, but also serve as examples for our residents. In our role as teachers and mentors, we must have thorough knowledge of the governance of cardiothoracic surgical education. The governing bodies of cardiothoracic surgical education are, The American Board of Thoracic Surgery (ABTS), The Residency Review Committee for Thoracic Surgery (RRC), and The Thoracic Surgery Directors Association (TSDA). Each of these governing bodies has the resident as its central core and theme. The functions of each individual component of the governance are as follows: The ABTS is responsible for testing and certification, the RRC evaluates residency programs for accreditation, and the TSDA is responsible for resident instruction, core curriculum, and education. Each component is a necessary governing body to develop the best thoracic surgery resident possible. Let us now look at each individual component.
The American Board of Thoracic Surgery was founded in 1948 and is composed of 17 members with a term of six years each. Since its predominant purpose is testing and credentialing, the board is responsible for the both the oral and written exams, and the recertification exam, Self-Education Self-Assessment in Thoracic Surgery, the practice review, and Continuing Medical Education. Its 17 members are drawn from the various thoracic disciplines. Board certification indicates that individuals have successfully completed an approved education program, and have been evaluated with an exam designed to assess the knowledge, experience, and skills required to provide high-quality thoracic care.
The purpose of the Residency Review Committee is to oversee training programs. It is composed of six members, including its chairman: two from the American Board of Thoracic Surgery; two from the American College of Surgeons; and two from the American Medical Association. The RRC is responsible for credentialing residency programs and determining the number of residents at each institution. Depending on its current status, a program is reviewed at one, three, or five-year intervals. The possible actions of the RRC are as follows: It can approve a program for a review at three or five years, or the review may be deferred; it may recommend probation or closing a program. The RRC ensures that accredited programs provide a resident the appropriately defined educational experience to be a proficient thoracic surgeon.
The Thoracic Surgery Directors Association was founded in 1978. Its purpose is to ensure quality teaching and an appropriate learning environment. It also maintains a list of board requirements and informs program directors of any changes in requirements for certification by the American Board of Thoracic Surgery. In addition, the TSDA is responsible for the thoracic core curriculum, the residency-matching program, and resident education.
It is the single purpose of each individual governing component to prepare individuals to practice cardiothoracic surgery in a manner that is safe, effective, and accomplished without forgetting the human needs of their patients. Having had the opportunity to be a member of two of these three governing organizations, the American Board of Thoracic Surgery and the Residency Review Committee, I can report to you that each strives to perform the function with which it is vested and to look after the best interests of the cardiothoracic surgical resident. It has been indeed an honor and a privilege for me to have served as a member of these two boards and their committees.
From Halsted's establishment of the Pyramidal Residency System at Johns Hopkins in 1899, as highlighted in the presidential addresses of Drs. Bender and Murray, to the rectangular system recommended by Churchill at the Massachusetts General Hospital, residency training has come a long way [1, 5–7]. Many of you here today went through the Halsted Pyramidal System at Hopkins or Vanderbilt. Churchill was on target when he developed the rectangular system, as it was a fairer test of training and competence [7]. Churchill emphasized that correct decisions are derived from good judgment, which is a combination of intelligence, knowledge, experience, and the continuous critical analysis of results [7]. His residency program was designed as education for uncertainty, with concomitant emphasis on equanimity. John Whiteham described the Churchill residency: "One cannot become aware of alternatives without some ability to tolerate uncertainty; and we cannot experience good judgment and common sense in reaching well-considered conclusions and wise action unless we can tolerate uncertainty with equanimity" [7].
I would now like to turn my attention to qualities that I think the complete cardiothoracic surgeon in the second millennium will be required to attain. After reading most of the cardiothoracic surgery Presidential Addresses for the past 30 years, today I share with you my own thoughts based on 30 years of academic clinical experience. Ours is the "Apollonian Quest", as stated by Aldo Castanaeda [8]. "Whether or not we can achieve it is by the aspects of circumstance, ability, determination, will, providence, and being the beneficiaries of our mentors who have instructed us so well [8]."
The title of my address, "The Complete Cardiothoracic Surgeon: Qualities of Excellence" will ring a familiar bell to those who are students of surgical history. A variation of this theme has been used three times before. As noted by Dr. Lawrence Cohn: In the Fourteenth century, the French surgeon Guy de Chauliac wrote, "What the Surgeon Ought to Be" [9]. In 1972, Dr. Andrew Morrow presented "What the Cardiac Surgeon Ought to Be" [10]. In 1999, Dr. Lawrence Cohn presented "What the Cardiothoracic Surgeon of the 21st Century Ought to Be" [9]. Using this as a paradigm, I give credit to Dr. Larry Cohn for his original ideas on this topic. I have taken the opportunity to expand this to what I think the "The Complete Cardiothoracic Surgeon Should Be and Associated Qualities of Excellence." I think that we, as leaders in the field of cardiothoracic surgery and teachers of the future generations of cardiothoracic surgical residents, should strive to attain these qualities.
In 1790, Guy De Chauliac said the traits of a surgeon are that he should be learned, he should be expert, and he should be ingenious and adaptable [9]. In 1972, in his Presidential Address to the American College of Vascular Surgeons, Dr. Andrew Morrow said a cardiac surgeon ought to be a physiologist, a cardiologist, an investigator, a skeptic, an expert surgeon, a competent surgeon, an anatomist, have a hobby, and have a sense of business.
In his 1999 Presidential Address presented to the American Association of Thoracic Surgeons, Dr. Larry Cohn listed a number of qualities that the cardiothoracic surgeon of the 21st Century should strive to attain [9]. He stated that they should include the following: (1) an excellent surgeon; (2) a physiologist; (3) an excellent teacher; (4) knowledge of health care economics; (5) versed in digital technology; (6) knowledge of new surgical technology; (7) a leader; (8) adaptable; (9) be persistent; (10) sense of history of the specialty, and (11) a humanist.
With Dr. Cohn's permission, I have expounded on his ideas and added my own personal thoughts to his list. The qualities of a complete cardiothoracic surgeon in the second millennium are as listed in Table 1.
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Qualities of the complete cardiothoracic surgeon |
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Academic cardiothoracic surgeons are expected to demonstrate excellence in not only outcome results but also the ability to train residents in an effective reproducible technique. When I was at the Mayo Clinic in the 1960s, Dr. Dwight McGoon stated that there are 122 steps in an aortic valve replacement from skin incision to skin closure: "Write those down, learn them, and you will do well."" Over the course of my six months with Dr. McGoon, I attempted to get them all down one-by-one in a small spiral notebook. Ultimately, at the completion of my rotation, he was willing to sit down and go through those steps with me. We should train residents in an effective reproducible technique, and the order in which we conduct a particular operation should be essentially the same in all cases. If our residents learn a standardized technique to approach a specific procedure, then they can learn the exceptions to the rule and do well. Equally important to the technical performance of the procedure is the judgment used in determining the type of operation to be done. It is my feeling that there is no substitute for excellent judgment. As long as one has excellent judgment, the hands will follow and technical excellence will be achieved. As a part of judgment, we must know our own capabilities and how to measure our results. We need to know not only our own ability to achieve a given technical result, but also our limitations, and we must never fail to ask for help in those cases in which we feel that someone could help us improve the outcome for our patient. Above all else, we must have absolute integrity and honesty in the operating room both with ourselves and with our residents. William Shakespeare said in Hamlet: "To thine own self be true, then thou cannot be false to any human." As a trainee of cardiothoracic residents, the manner that the senior surgeon displays in selecting patients for operation and his conduct of the operative procedure itself are the all-important tools in the training of young, future cardiothoracic surgeons.
Andrew Morrow pointed out in his Presidential Address that the attributes of an expert surgeon include the wisdom of selecting patients for surgery and the conduct of the operative procedure [10]. Morrow stated: "A surgeon and only the surgeon should make the all important final decision as to whether a patient is a candidate for an operation and, if so, what procedure is the most appropriate." He reminded us of one of the most poignant statements of Blalock, "The fact that a patient is going to die does not necessarily mean that he should be operated upon" [10]. Judgment is almost as important as the technical ability to carry out the procedure itself.
2. The complete cardiothoracic surgeon of the second millennium must have a detailed knowledge of cardiorespiratory physiology
First, he should have a knowledge of pulmonary physiology as it relates to pulmonary function testing. (Note: The term "He" as used in the manuscript is not gender specific and refers to he or she depending upon whether the surgeon is a male or female. It is not meant to refer to the male gender specifically.) The complete cardiothoracic surgeon must have an in-depth knowledge of the extent and limits of pulmonary resectability based upon four levels of pulmonary screening. He should be able to interpret the routine pulmonary function studies. He should know their significance and when pulmonary exercise testing is indicated and how to interpret the results of MVO2 (maximum oxygen consumption), exercise oximetry, and the limits of the six-minute walk study. In addition, he should know when pulmonary rehabilitation is indicated and when it may be useful in the preparation of the marginal resection candidate. The second large area of knowledge of which the cardiothoracic surgeon should be aware is the interpretation and application of the results of cardiac testing. He should have thorough knowledge of transesophageal echocardiography, cardiac catheterization data, and the ability to interpret coronary angiography.
3. The complete cardiothoracic surgeon must also be an excellent teacher and have a knowledge of cardiothoracic surgical education
He must instruct and inspire our thoracic surgery residents to seek further knowledge, to raise questions, and to share information as well as provide them the opportunity to write and participate in surgical research. He should inspire in them the concept that a cardiothoracic surgeon is "a surgeon and something more." In addition, he must have an in-depth knowledge of cardiothoracic surgical education as effected by The American Board of Thoracic Surgery, the Residents Review Committee, and The Thoracic Surgical Directors Association.
4. The complete cardiothoracic surgeon must be an excellent radiologist
Today's cardiothoracic surgeon must have the ability to interpret three-dimensional knowledge from an anatomic, physiologic, and radiographic viewpoint. His or her knowledge of anatomy and surgery teach them, based on experience, what is possible and what is not possible to accomplish. It is a sinequanon that the surgeon never knows for sure what can be accomplished until he or she is at the operating table. An almost impossible-looking CT scan of an advanced stage IIIA or IIIB lung cancer with invasion in the mediastinum may appear unresectable, but when one is there it may be possible to resect part of the atrial and/or cava wall and excise the tumor. Only the surgeon has the ability to interpret anatomic, physiologic, and radiographic data because of his unique experience in all three modalities.
5. The complete cardiothoracic surgeon must have a detailed knowledge of healthcare economics
The complete cardiothoracic surgeon must have a detailed knowledge of the impact of government on thoracic surgical education and healthcare economics. He must be willing to grapple with economic issues and work toward their solutions. In addition, he is required to know the economic consequences of outcome parameters in adult cardiac, thoracic, and congenital heart surgery. The outcome parameters will be the standardized measure by which all surgeons are compared. As pointed out by Dr Robert W. Anderson of Duke University, the major issues in healthcare economics are listed in Table 2
[11].
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The declining subsidization of thoracic surgical education is widely affecting all training institutions. It is obvious that academic medical centers can only survive if they develop an aggressive strategy to deal with these business aspects in the medical marketplace. Anderson's paper should be read by all who are interested in the specific economic aspects of our healthcare in the United States.
6. The complete cardiothoracic surgeon must have an in-depth knowledge of new surgical technology
The complete cardiothoracic surgeon must have knowledge of robotics, lasers and photo chemicals, transplantation immunology, gene therapy, molecular markers, oncologic principles, and the new and emerging field of digital technology and how it impacts all of cardiothoracic surgery. Robotic surgery is now becoming a mainstay in several institutions in our country, and the utilization of robotics in the performance of minimally invasive procedures is crossing all aspects of our field from minimally invasive valve replacement to total robotic valve replacement and to the performance of minimally invasive thoracic procedures as well. In addition, the ability to destroy certain tumors by photodynamic therapy with laser ablation is now practiced in many medical centers. The future with gene therapy, both in cardiac disease and oncologic therapy for lung cancer, is in the forefront of many laboratory investigations. Emerging digital technology is affecting all of medicine, and one has to learn this in-depth knowledge or be left behind.
7. The complete cardiothoracic surgeon of the second millennium must be a leader
The complete cardiothoracic surgeon must be a leader in the local healthcare environment; he must be a leader in the training of residents; he should strive to be a leader in national specialty organizations; in essence, he becomes a renaissance human or Thomas Moore's "A human for all seasons." He is an individual that others will want to emulate. Leadership involves taking responsibility to direct the action of others and taking responsibility and accountability for both successes and failures. In his excellent book, Leadership Secrets of Attila the Hun, Wes Roberts points out that "You must have a passion to succeed, a passion that drives you to prepare yourself and your colleagues to excel. By their actions, not words, do leaders establish the morale and integrity of their subordinates, and by the ability to make timely and difficult decisions" [12]. He points out that "Leadership Effectiveness = Results x Personal Qualities." [12]. Kouzes and Posner stated, "The first milestone on a journey to leadership credibility is clarity of personal values" [12]. Dr. William J. Mayo said, "Integrity is the basis of trust. Trust is a bonding of caring, and when the prognosis for trust is poor, the chances for a good outcome diminish. Trust and caring are almost synonymous" [13]. Now, more than ever, we must use our leadership ability and skills to broaden our scope and think in terms of healthcare problems at both the local and national levels.
In summary, Winston Churchill, in 1951, said of the ability to lead: "I can practice in an honorary fashion the arts of surgery and medicine... being temperamentally inclined to precision and a sharp edge, it might be thought that I should choose the surgeon's role" [14].
8. The complete cardiothoracic surgeon must be adaptable
The complete cardiothoracic surgeon must be adaptable to change. He must consider new ideas and he should never fail to keep an open mind. Larry Cohn stated: "The most successful thoracic surgeons are, by their very nature, adaptable because they deal with new predicaments every day in the operating room, in the ward, and in the clinic" [9]. As Friar Roger Bacon stated in his Opus Magnus of the 13th century: "The four stumbling blocks to grasping the truth are: one, the pattern set by our elders; two, longstanding custom; three, the popular belief, therefore it should be held; and four, the hiding of our own ignorance by making a display of our apparent knowledge. Every human is involved in these things in every walk of life, in every occupation, and they arrive at the same conclusions by their worst arguments" [15].
As J. Cassell in 1987 pointed out, "Surgeons are rarely allowed the luxury of second thoughts. At the operating table, the surgeon must manifest decisiveness, certitude, control; emergencies must be resolved, unexpected findings anticipated, and the advantages exploited" [16].
9. The complete cardiothoracic surgeon must have a knowledge of the history of cardiothoracic surgery
Wangensteen stated that: "If all problems in medicine could be taught with special emphasis on a historical approach, every physician would be better prepared to cope with future problems" [17]. Celsius stated in the 4th century that there are three ways to treat a patient: "Diet, medicine, and surgery, but only surgery works" [18]. Wangensteen further stated in 1975, "May the spirit of inquiry, the love of learning, and appreciation of the History of Medicine create in our medical schools an intellectual atmosphere that will heighten greater medicine's commitment and accountability in its service to humanity" [19]. Wangensteen stated in his address concerning the education of surgeons in 1940: "The past never returns, but the character of the future can be determined in part by what is done in the present" [19]. Thomas Jefferson, in stating the qualities of the ideal physician said that we as physicians should be inquisitive; we should have a concern for people; we should be intelligent; and we should believe in the scientific method [20]. A thorough knowledge of the history of the specialty and of individual disease processes will make the complete cardiothoracic surgeon a better teacher, give him or her a greater understanding of the condition, and enable him or her to take advantage of previous research.
10. The complete cardiothoracic surgeon should develop, to the best of his ability, the quality of being persistent
Persistence is perhaps the most important personal quality that a complete cardiothoracic surgeon can develop. It is often the key to a successful outcome. As Cohn pointed out, many times we have experienced success in a very difficult operation by simply adhering to our game plan in the operating room, no matter what the obstacles [9]. Gustav Mahler stated: "For success, nothing in the world can take the place of persistence; talent alone will not be successful because nothing is more common than the unsuccessful human with talent. Education alone will not be successful because the world is full of educated fools. Persistence and determination are alone omnipotent" [15]. "It is the ability to keep on going and trying through the valleys in the late night hour in the operating room when success often comes and a successful outcome for the patient results" [9]. For the surgeon who is persistent and has expert knowledge and technique, rarely is there an adverse outcome.
11. The complete cardiothoracic surgeon must also be a humanist
Dwight McGoon, in his Presidential Address to the AATS in 1984 said: "All efforts in research, education, administration, writing, editing, and long hours of intensive labor at the operating table have inherent and transcendent value only in one respect ... as an unselfish expression by skilled and dedicated surgeons of a concern for the welfare of needful human beings" [21]. We must remember that our patients are our primary concern and it is for them we have dedicated the long years of training. We must never lose our compassion for the patient. As Aldo Castanaeda stated in his Presidential Address: "Our specialty is not merely an applied science and technical discipline, it also involves an important aesthetic component, juxtaposing art and science, and demanding, in addition, honesty, courage, judgment, vision, compassion, and a commitment to the pursuit of excellence" [8]. He points out that: "there is an unresolved paradox in which we often find ourselves: Our Hippocratic obligation to immerse ourselves in, and at the same time, the need to distance ourselves emotionally from the struggle of human survival." "The privilege to participate in preserving and improving life provides us with our purest professional satisfaction" [8]. He further states: "There is a widening gap between science and the humanities. Often we find well-trained professionals who have mastered scientific facts, statistical proofs, and surgical techniques but who lack more elusive qualities such as respect for the dignity of human, empathy, humility, and interpersonal skills" [8].
Castanaeda added: "The humanities open to us the uncertainty that is our common fate as travelers and sometimes help us to better accept the hazard of the journey. Humanities offer us a vision that transcends our own fate and, very importantly, teaches us understanding" [8]. Robert Frost stated that: "Living on the horizons edge, the growing age of discovery for that is where the beauty that lurks in danger, defiance, defeat, and victory lies" [21].
As Dr. Hal Urschel pointed out in his Presidential Address to the STS in 1984 regarding humanism and surgery, Dr. Churchill separated surgery into four compartments, which he called "The Content of Surgery" [7] (Table 3). Churchill states that: "Humanism is the safe application of science to human needs" [7].
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13. The element of faith
Regardless of our religious background, there is something of "faith" that lies embedded within the inner nature and soul of us all. Jeremiah 6:16 says, "Thus saith the Lord, "stand ye in the ways, and see, and ask for the old paths, where is the good way, and walk therein, and ye shall find rest for your souls. Certainly, in our times of inner need, we have sought sustenance and support through faith. In the unique moments we share with our patients and their families, faith is there lending strength and instilling hope. There arises within each individual, whatever his upbringing or religious background, that element of faith that there is something higher than we, who walks with us along the way. As George Crile, Jr. so eloquently stated regarding the element of faith: "No physician, sleepless and worried about a patient, can return to the hospital in the midnight hours without feeling the importance of his faith. The dim corridor is silent; the doors are closed. At the end of the corridor in the glow of the desk lamp, the nurse watches over those who sleep or lie lonely and wait behind closed doors. No physician entering the hospital in these quiet hours can help feeling that the medical institution of which he is part is in essence religious, that it is built on trust. No physician can fail to be proud that he is part of his patient's faith" [22].
I would like to close with two short thoughts. Dr. Floyd Loop stated that the qualities of the ideal surgeon are scholarship, leadership, courage, and faith [23]. I would agree that these are absolutely correct. I would like to quote from an extremely close friend of mine, Dr. Clement A. Hiebert, now retired. In one of the most eloquent addresses ever given in cardiothoracic surgery, Dr. Hiebert, in his 1988 Presidential Address to the New England Surgical Society, pointed out the five attributes of surgery: one, it has a beginning and an end; two, it can be completed in a number of hours; three, it has an attribute of stress to overcome; four, it has a focused activity; and five, it has the quality of "in-chargeness" [24]. He asked the questions: "Can we achieve fulfillment? Is the grail beyond our reach? Are we fettered forever by the mundane and the material? Can we recapture the sense of wonder and worthwhileness in surgery?" He stated: "The only true happiness comes from squandering ourselves for a purpose. The best-kept secret in surgery is to find fulfillment. You must lose yourself in something larger than the operative field. It is then that we can achieve the fulfillment of mind, heart, and spirit" [24].
In conclusion and as an epilogue to this Fiftieth Presidential Address, I ask myself the question, would I do it again?
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Ladies and gentlemen, past Presidents, members and guests, it has been a distinct honor and privilege to serve as the Fiftieth President of this great association. I thank you from the bottom of my heart.
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