| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 2005;79:S2232-S2237
© 2005 The Society of Thoracic Surgeons
Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
Accepted for publication February 23, 2005.
* Address reprint requests to Dr Crawford, Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas St, Room 409, PO Box 250612, Charleston, SC 29425 (E-mail: crawfrdf{at}musc.edu).
Presented at the 4th Annual Lillehei Heart Institute Symposium Celebrating the 50th Anniversary of Open-Heart Surgery by Cross Circulation, Minneapolis, MN, Oct 19–20, 2004.
 |
Abstract |
|---|
 Top Abstract IntroductionDeclining Interest in Medical...Changing Demographics of...Lifestyle of Surgical Residents...Changing Expectations of SocietyAssessment of Surgical EducationReferences |
|---|
|
Introduction |
|---|
|
TopAbstractIntroductionDeclining Interest in Medical...Changing Demographics of...Lifestyle of Surgical Residents...Changing Expectations of SocietyAssessment of Surgical EducationReferences |
|---|
Thoracic surgery matured rapidly during World War II, and in 1948 a subsidiary Board of Thoracic Surgery was established. The American Board of Thoracic Surgery (ABTS) subsequently became an independent board in 1971. Other milestones in thoracic surgery education have included the Thoracic Surgery Residency Review Committee (RRC) founded in 1967, The Thoracic Surgery Directors Association (TSDA) in 1977, the Matching Program in 1982, the first In-Training Examination in 1983, and the Joint Council on Thoracic Surgery Education in 1996.
Most students, residents, and even surgeons educated in the United States probably believe that thoracic surgical education is reasonably similar throughout the world. Such is not the case. In Europe the time required to educate a cardiothoracic (CT) surgeon ranges from 2 to 9 years, and in most cases is 5 or 6 years. Clearly, there are different ways to educate CT surgeons.
Many positive changes have occurred since Alexander developed the first thoracic surgery residency program. The TSDA has been responsible for introducing the matching program, the development of a standardized curriculum, a computer-based prerequisite curriculum for incoming residents, and a new Web-based educational program for current residents. The Thoracic Surgery RRC has developed a rigorous process for program evaluation and accreditation that emphasizes education over service and in recent years has closed or forced reorganization of programs which fail to do this. The RRC recently indicated that failure of a program to match for 2 years in a row will trigger an immediate site visit and probable probation. The examination process of the ABTS has been strengthened by the adoption of statistically valid, criterion-referenced written and oral examinations. After pioneering Internet-based in-training examinations, the ABTS will in November 2004 administer the written examination by computer at multiple sites, thus decreasing travel expense and inconvenience. The Cardiothoracic Surgery Network (CTSNet) has proven to be a valuable educational tool by providing access to online databases, journals, and multimedia programs.
Despite these significant advances, many challenges remain and must be addressed to increase the interest in surgical careers in general and then specifically in CT surgery. These challenges include the following:
|
Declining Interest in Medical School and Surgery |
|---|
|
TopAbstractIntroductionDeclining Interest in Medical...Changing Demographics of...Lifestyle of Surgical Residents...Changing Expectations of SocietyAssessment of Surgical EducationReferences |
|---|
Because historically general surgery has been the only pathway to CT surgery, this decline in interest in general surgery has real implications for CT surgery. The number of residency positions available in CT surgery has remained relatively constant at about 140, but the number of graduates of US medical schools interested in thoracic surgery declined from 167 in 1994 to 99 in 2004. This year there were only 134 total candidates for the CT match, and 17 positions and 17 programs did not fill. For a specialty that was once perhaps the most competitive of all, there are now not only fewer US-trained candidates than positions available but fewer total candidates than positions available.
Clearly, the current perception among residents is that fewer CT surgeons will be needed in the future. This perception has been fueled by the decline in available jobs for graduating residents. In a survey of the 2003 graduates by the Thoracic Surgery Residency Association (TSRA), 71% expressed significant difficulty in finding a job and 30% chose a job because it was the only one offered. [4] Nineteen percent received no job offer, and 17% elected to pursue additional training while waiting to find a job. There has been a proliferation of "fellowships" which have been filled mostly by graduating CT residents unable to find a suitable job. Cardiothoracic residents currently completing a very long educational process are understandably unhappy.
Does this current situation reflect the future of CT surgery or is this a relatively temporary situation soon to be replaced by an increasing demand?
Russell Coile, a well-known futurist in the area of health care and the author of Health Trends, has made the following observations [5]:
Since 1975, the number of practicing CT surgeons has been relatively constant while the number of cardiologists has increased 734%. (Despite this huge increase in cardiologists, no one disputes projected needs for many additional cardiologists during the next two decades. However, cardiology as a specialty may be suffering from the same lifestyle issues as cardiac surgery, and if recent trends continue, a majority of America’s future cardiologists will also be international medical graduates.)
The good news for all heart specialists and hospitals is that the rapidly aging population guarantees a steady stream of patients for the next two to three decades, but which heart specialists will benefit?
The bad news, at least for CT surgeons is that:
Other issues that could potentially impact CT surgery manpower needs include the following:
Each of these has the potential to significantly increase or decrease the future need for CT surgeons.
So far the focus has been on the potential demand for cardiac surgeons—what is known about the supply? The American Association for Thoracic Surgery (AATS) and The Society of Thoracic Surgeons (STS) have sponsored manpower surveys at approximately 5-year intervals since 1976 [7–9]. The 2000 Manpower Study found that by 2010, 50% of CT surgeons who were practicing in 2000 planned to be retired [8]. If you do the math based on these projections, you come up with some interesting results. There were approximately 4,000 actively practicing CT surgeons in the year 2000. If 50% or 2,000 retire by 2010, this would leave only 2,000 continuing in practice. There are currently about 90 CT surgery residency programs producing about 140 CT surgeons per year. In 10 years, this would result in approximately 1,400 new CT surgeons. Therefore, by year 2010, 2,000 surgeons who were practicing in year 2000 will have retired, and they will have been replaced by only 1,400 new surgeons, leaving a deficit of 600 practicing CT surgeons. Other factors also impact this estimate.
Richard Cooper noted in 2002 that like the general population, the physician workforce is also aging [10]. This includes CT surgeons, whose mean age has increased from 46 years in 1976 to 55 years in 2003 [9]. He found that older physicians and female physicians work fewer hours, perhaps equivalent to 0.8 to 0.90 full-time equivalents. He also noted that the current generation of physicians places greater emphasis on personal time and this translates into new graduates also equating to perhaps 0.8–0.9 full-time equivalents when compared with previous generations. When Cooper’s observations are factored into the 2000 AATS/STS Manpower Survey, it translates to an estimated 3,100 CT surgeons (compared with 4,000 in 2000) who will be practicing in 2000 to 2012. They will serve, however, a much larger patient population including 15 million more patients older than 65 years of age than today.
I believe that because of the decreasing number of CT surgeons, the continued population growth, especially in the elderly component, and the growing epidemic of obesity, diabetes, and related diseases, the current difficulties in the job market are temporary and we could be headed toward a real shortage of CT surgeons in the next two decades, despite the continuing inroads made by cardiology and other specialties.
In addition to job availability, other factors that currently discourage the choice of a surgical career by medical students include reimbursement and malpractice issues. Hopefully, few of us chose a career in surgery for purely economic reasons, and society is unlikely to have much sympathy for our small profession unless they understand that further decreases in reimbursement will progressively limit their ability to access truly quality surgical care. Malpractice issues have escalated to a crisis level in many states not only for CT surgeons but for other high-risk specialties as well. Perhaps the recent initiative by our specialty and others in the coalition of Doctors for Medical Liability Reform will help, but ultimately it will again be our patients who will be most influential on our behalf when they realize how this issue is limiting their access to quality health care.
The bias of medical school admission committees against specialty careers must be overturned. We must identify and encourage students interested in surgery very early during medical school and serve as their mentors and advisors. Curriculum changes including true redesign of the fourth year could potentially shorten surgical residencies of all types by a full year, but academic surgeons must take time to serve on curriculum committees if we expect such changes to be made. Surgical faculty must be acutely aware of their importance as role models and transmit more of the satisfaction obtained from patient care, research, and teaching instead of focusing on unhappiness with government regulation and reimbursement. Our current 7- to 10-year process for training a CT surgeon must be shortened, as this long pipeline both discourages students and makes it impossible to respond quickly to changes in demand.
|
Changing Demographics of Students and Residents |
|---|
|
TopAbstractIntroductionDeclining Interest in Medical...Changing Demographics of...Lifestyle of Surgical Residents...Changing Expectations of SocietyAssessment of Surgical EducationReferences |
|---|
Despite the increase of women in medical schools, the number of women general surgery residents has remained constant at about 20%, and only 4% of CT residents are women. I believe that women are just as fascinated by the technical aspects of surgery as men, but they are simultaneously afraid that the lifestyle will be intolerable. This problem is not isolated to the surgical specialties. Although 39% of internists are women, only 6% of cardiologists are women. An optimistic view is that women represent virtually an untapped source for future CT surgeons and cardiologists.
However, surgical residency and the current practice of CT surgery are not particularly friendly to women. If we are to attract more women into surgical specialties, we must recognize their special needs. The emphasis of education over service, the 80-hour workweek, team continuity of care, and the gradual increase in women surgeons who can serve as role models should help in this regard. Surgical residency programs must be permitted increased flexibility by the RRC to more easily address medical leave for pregnancy. We should consider shared residency positions, which, while requiring more years for completion, would allow women surgeons to begin a family at an earlier age.
|
Lifestyle of Surgical Residents and Practicing Surgeons |
|---|
|
TopAbstractIntroductionDeclining Interest in Medical...Changing Demographics of...Lifestyle of Surgical Residents...Changing Expectations of SocietyAssessment of Surgical EducationReferences |
|---|
As the interest in surgery has declined, interest in specialties with controllable lifestyles such as radiology, emergency medicine, dermatology, and others has increased. When I talk to third-year medical students rotating on surgery and ask what will be the most important factor influencing their choice of a career, almost invariably the first answer is "lifestyle." The increasing importance of lifestyle has been confirmed by several recent publications [13–15].
Cardiothoracic surgeons and especially CT surgical residents are not perceived as having a particularly good lifestyle primarily because of the number of hours worked by both residents and surgeons in practice. The newly mandated 80-hour workweek should have a positive effect in this regard and may largely be responsible for the increased interest in surgery in this year’s match. However, the new work-hour rules present real problems. Surgical residents will miss some operative procedures, conferences, and clinics, and surgical residencies may have to be lengthened to maintain these educational experiences. Perhaps as a result, several 2-year thoracic surgery programs have applied to become 3-year programs. Virtually all programs require significant financial assistance from their hospitals for physician extenders to meet service requirements previously provided by residents. More time away from the hospital will require residents to assume increased responsibility for self-education. A new initiative entitled "e learning," which is being developed by the Joint Council on Thoracic Surgery Education and the TSDA, may have enormous potential in this regard.
The work-hour regulations do not permit the type of continuity of care provided by previous generations of residents and surgeons. Continuity of care has by necessity become more of a team effort, and we must teach residents how to do this without compromising patient safety. In the process, the responsibility and accountability for the patient’s welfare that has characterized surgeons must not be lost. Team continuity of care involving the attending surgeon residents, intensivists, and others could provide both superior patient care and the opportunity for a better lifestyle for the surgeon. I am especially concerned about the almost overnight development of a "shift mentality" among surgical residents. I am also concerned about the rigidity of these work-hour requirements and especially by the effects on chief residents in the surgical specialties.
Our CT residents no longer take call in the hospital, and the floors are covered by physician assistants at night. The intensive care units (ICUs) are covered by a combined general surgery and anesthesia critical care team backed up by CT residents at home. There have been a few dropped balls but no real disasters with this approach. Our CT residents appear more rested and happy, and there is evidence that at least some of the increased time at home is used for reading and studying. However, they do not like to be told that they have to leave the hospital and thereby miss scrubbing in on an important case. It is inevitable that work-hour limitations will also be applied to practicing surgeons as is already the case in Europe.
|
Changing Expectations of Society |
|---|
|
TopAbstractIntroductionDeclining Interest in Medical...Changing Demographics of...Lifestyle of Surgical Residents...Changing Expectations of SocietyAssessment of Surgical EducationReferences |
|---|
Future residents will learn to perfect basic surgical skills in the laboratory and more advanced skills by surgical simulation. Residents and even practicing surgeons may have their operative skills assessed and graded using techniques currently used by coaches to evaluate professional athletes. Further advances in technology including imaging, simulation, and virtual reality will provide important tools, not only for residents’ education but also as ways of measuring and maintaining technical competence after residency is completed.
In the future a significant part of the education of cardiac and vascular surgeons, cardiologists, and perhaps interventional radiologists will involve the mastery of a fundamental core of knowledge about cardiovascular disease before moving on to the technical skills peculiar to the individual specialty, and even these will increasingly overlap. The same will be true for the thoracic surgeon, pulmonologist, gastroenterologist, thoracic oncologist, and radiologist. Eventually this will result in a realignment of medical school faculty from traditional departments of medicine and surgery into departments focused on a particular system such as departments of cardiovascular disease or digestive disease.
|
Assessment of Surgical Education |
|---|
|
TopAbstractIntroductionDeclining Interest in Medical...Changing Demographics of...Lifestyle of Surgical Residents...Changing Expectations of SocietyAssessment of Surgical EducationReferences |
|---|
The emphasis is changing from evaluating process to evaluating the outcome of resident education with success on examinations as only one of the measurements. Residents will now be evaluated not only by faculty but by peers, nurses, patients, and others in the six core competencies of (1) patient care, (2) clinical science, (3) practice-based learning, (4) interpersonal skills and communication, (5) professionalism, and (6) systems-based practice. The Boy Scouts of America have successfully used this method for years. One only progresses to Eagle Scout by earning a certain number of merit badges, which signify competence in a particular area such as lifesaving or woodworking. Surgical educators must focus on competence as we must assure the public and hospitals by objective standards that an individual is competent to perform certain surgical procedures. In effect CT residents may be required to earn "merit badges" in coronary bypass procedures, valve surgery, transplant surgery, congenital heart surgery, surgical oncology, and so forth. Not all residents will progress at the same rate, and successful accomplishment of specific objectives may determine the length of surgical residency rather than an arbitrary number of years. The implications of this for thoracic surgical educators are enormous, particularly given the rate of turnover of thoracic surgery program directors, which currently approaches 25% to 30% per year!
As a result of these societal, environmental, demographic, and other external forces, significant change in thoracic surgical education is beginning to occur. There has been a growing consensus that the traditional 2-year thoracic residency is too short to include everything that the specialty of thoracic surgery now encompasses [17]. Table 1 demonstrates the components of thoracic surgery at the time of the first board examination in 1949 as well as subsequent additions that represent current CT practice. For these and other reasons we moved to a 3-year program at the Medical University of South Carolina more than 15 years ago. This, however, adds a year to an already lengthy residency.
|
Although a welcome change, I believe that this new plan is only an interim step toward a real change in surgical education. Ultimately individuals would use a significant portion of the fourth year of medical school studying the basic science of surgery. The first 3 years after medical school would be spent in a core program developing the basic surgical skill set in areas such as gastrointestinal, pediatric, and vascular surgery, for example. Near the end of the core program the individual would take an examination, and, if successful, would then be eligible to begin a residency in a subspecialty such as CT, pediatric, plastic, and colorectal surgery or in a specialized residency program in an area currently included in general surgery such as vascular, trauma and critical care, gastrointestinal, surgical oncology, or transplantation. Such a program would obviate the need for subsequent fellowship years in most cases, thus shortening the educational process. Recently the American College of Cardiology held a Bethesda conference on "Cardiology’s Workforce Crisis" [19]. The recent changes made by the ABTS were applauded, and it was suggested by one subgroup that now was the time to shorten the educational process for cardiologists by developing a combined 5-year program.
It is impossible to predict exactly how these changes endorsed by the ABTS and ABS will affect thoracic surgical education. The changes have been made carefully and deliberately and with the best possible intentions. For those who prefer, the traditional route with full certification by both boards is possible, and programs and individuals who want to continue this approach are encouraged to do so. Although thoracic surgery is an outgrowth of general surgery, and the close association of our specialties has been important, I believe that the fund of knowledge and skills required by thoracic surgery today have now increased to the point that most of the time allocated to a thoracic surgeon’s education must be devoted to those areas unique to CT surgery with less emphasis on general surgery.
I predict that ultimately the CT resident educational process will evolve either into the "core plus subspecialty" (3/3) process or into a 6-year completely integrated residency that matches directly out of medical school. I believe that the current "one-size-fits-all" approach by the Thoracic and General Surgery RRCs to resident education will change, that we will see increased subspecialty tracking, and that there will be increasing educational overlap with related specialties such as between cardiology and cardiac surgery or thoracic surgery and pulmonology. Although the resistance to substantive change cannot be underestimated, these proposals would streamline surgical education and allow individuals to focus on their true interests and complete their residency at an earlier age.
In the process we must focus on remaining relevant. Recently the Dow shed three of its oldest members (AT&T, Eastman Kodak, and International Paper) for the stated reasons that they "poorly reflected the US economy"—in other words, they were no longer considered relevant. Our specialty goes back to 1917 but will not survive by clinging to the same old operations and trying to maintain the status quo. Thoracic surgery and its educational process must change and evolve if we are to remain relevant in the future care of patients with cardiovascular disease.
|
References |
|---|
|
TopAbstractIntroductionDeclining Interest in Medical...Changing Demographics of...Lifestyle of Surgical Residents...Changing Expectations of SocietyAssessment of Surgical EducationReferences |
|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
