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Section of Cardiothoracic Surgery, Department of Surgery, The University of Cincinnati, Cincinnati, Ohio
* Address correspondence to Dr Merrill, 231 Albert Sabin Way, ML0558, Cincinnati, OH 45267-0558 (Email: walter.merrill{at}uc.edu).
It is an honor to represent the faculty, staff, and residents of the University of Cincinnati Section of Cardiothoracic Surgery, and all of us thank Dr Reed for selecting our program to present the Kent Trinkle Education Lectureship today.
As most of you know, Dr Trinkle was one of our predecessor giants in thoracic surgery, in part due to his contributions to this organization and to the training of residents. While this recognition of Dr Trinkle is entirely appropriate and fitting, examination of the minutes from the Council meeting held November 4, 1992, indicates that the president-elect, Dr Gordon Murray, "commented that the 1993 program will be dedicated to recognizing the accomplishments of the thoracic surgical programs within the Southern Thoracic Surgical Association (STSA) boundaries." Furthermore, "Dr Murray suggested this might be an ongoing lecture presented annually at the meeting." In addition, the minutes from the Council meeting held April 24, 1994, indicate as chair, "Dr Murray encouraged that the STSA continue to invite a thoracic surgery program director within our geographical boundaries to present information dealing with his program."
We hereby acknowledge our debt of gratitude to Dr Murray for his original suggestion to establish an annual lectureship highlighting thoracic surgery education. Our fledgling program at the University of Cincinnati is honored to join the list of those who have made presentations previously.
In the interest of full disclosure, it should be noted that the presentation today is out of order, or at least irregular, in that there is a small stream known as the Ohio River that separates Cincinnati and much of Ohio from the previously mentioned STSA boundaries. We will assume that Dr Reed was well aware of this fact and simply took the prerogative of the president and chose to ignore it.
The title chosen for today's presentation is taken from Andrew Lytle's foreword to Shakespeare's Insistent Theme, a collection of essays by Charles Harrison, former chair of the English Department of the University of the South. Lytle says, "He knows that instruction carries less weight when the teacher does not love his students" [1]. It is hoped that the significance of the title will become more apparent over the course of this presentation.
An emphasis on the education of surgery residents has been a hallmark of the Department of Surgery of the University of Cincinnati for many years, particularly since the arrival of Dr George Heuer in 1922. Dr Heuer established the third modern formal surgery training program in this country. His publications concerning resident education are classics and should be widely read today.
For example, "The men I would seek to develop shall have acquired a spiritual experience as rich as their surgical experience, which enables them to follow only the highest ideals of medicine" [2]. His associate, Dr Noland Carter, said of Dr Heuer, "He has always intensely concerned himself with each of ‘his men,' spending much time in planning their careers, stimulating them to improve themselves, and offering kindly and constructive criticism, not only of their professional activities, but also of their ideals" [3]. May all of us who are entrusted with the responsibility and privilege to educate young surgeons be inspired to follow Dr Heuer's good example of loving our students.
The Section of Cardiothoracic Surgery was formed in 2002 by aligning the Division of Thoracic Surgery with the Division of Cardiac Surgery and with the Division of Pediatric Thoracic Surgery. The goals established in 2002 were to recruit new faculty, to expand clinical programs, to develop new research programs, and to develop an approved resident training program in cardiothoracic surgery.
Although the reasons to establish a training program were multiple, we like to think that we paid attention to Dr Trinkle's advice, "but the only real reason for having a residency training program is that you want to train residents" [4]. As expected, these efforts were met with considerable skepticism, especially given the decline in the number of applicants for training positions in recent years. Encouragement to proceed came from several persons, including Dr Ben Wilcox, who maintained that it is important to establish a robust presence of our specialty's programs in major educational centers in the hope that general surgery residents and students will be inspired to enter the speciality.
It must be acknowledged that the training program is most properly viewed as the Cincinnati interpretation of much that has been learned from two important mentors, Dr Vincent Gott and Dr Harvey Bender. In his Southern Thoracic Surgical Association Presidential address Dr Bender stated, "obviously it is our desire to prepare individuals to practice the specialty in a manner that is safe, effective, and accomplished without forgetting the human needs of our patients" [5]. Dr Bender went on to describe the essential features of a properly constructed training program. Those features include teaching of the broad principles of pathology and physiology, provision of an environment conducive to the acquisition of knowledge and manual skills, recruitment and development of an expert faculty, instilling the commitment to the management of all aspects of the patient's illness, the assumption of total responsibility for all aspects of patient care and for any result that is less than optimal, and faculty involvement in all aspects of patient care.
How have we attempted to apply those principles? First and foremost, everything that is done has to be subjected to honest and bold scrutiny. The underlying theme in all of our work is the expressed desire for constant improvement, enunciated in the question, "What are we doing that cannot be improved?" Of course, the answer is nothing.
Second, the program has attempted to foster innovation in clinical, research, and educational matters. The section has been honored with the opportunity to host the recently inaugurated journal of the International Society of Minimally Invasive Cardiovascular and Thoracic Surgery, Innovations, with Dr Flege serving as associate editor.
Another important emphasis of the section has been placed on collaboration. Examples include the opportunity to develop, in conjunction with the College of Medicine, the UC Summer Surgery Experience, an in-depth 2-week immersion program for college undergraduates interested in attending medical school, and the joint effort with the Thoracic Surgery Residents Association and the Thoracic Surgery Directors Association to develop the resident Cardiothoracic Technology Symposium, a yearly 3-day intensive hands-on laboratory and lecture experience for cardiothoracic residents.
Much of the care that we administer, especially in the intensive care unit, is undertaken in a multidisciplinary fashion utilizing the processes of collaborative rounding. This provides a nonhierarchic relational infrastructure that focuses on teamwork and communication and places the patient and family in the center of all care processes and decision making. In addition, formalized and structured time outs and debriefings occur before and after each case in the operating room. Efforts to foster high-capability, high-performance teamwork are greatly enhanced by weekly team meetings in which outcomes, processes of care, and communication and organizational effectiveness are openly discussed.
You might ask, well, what has been accomplished? Our first cardiothoracic resident, and our only graduate at this point, John Mehall, is largely responsible for and deserves most of the credit related to the establishment of the resident Cardiothoracic Technology Symposium. John served as president of the Thoracic Surgery Residents Association. Perhaps it is not an accident that the breadth of the training program helped John to develop a strong interest and expertise in minimally invasive stand-alone operative procedures for atrial fibrillation, robotic cardiac surgery, and video-assisted thoracic surgical lobectomy.
The training program has matched a resident each year, and we are very pleased with the progress and accomplishments of Dr Jeff Garrett and also Dr Julian Guitron.
Since 2002, seven general surgery residents have spent extensive time in the research laboratories of our faculty. Four general surgery residents have matched in a cardiothoracic surgery resident training program. To borrow Dr Kron's phrase, Cincinnati has become a "net exporter" of talent to prestigious training programs around the country.
Cincinnati's General Surgery and Cardiothoracic Surgery trainees have distinguished themselves by receiving well-deserved recognition, including several scholarships and awards. We were also very pleased to host Emanuel Bessay, from Northwestern University School of Medicine, as a 2007 American Association for Thoracic Surgery medical student summer research award winner.
How has anything been accomplished? First and foremost, broad institutional support for the program has been unwavering despite turnover in departmental, College of Medicine, and hospital leadership. The faculty and staff have worked diligently to improve the program, and the residents have performed in an exemplary manner. There is an organized curriculum, including a spectrum of rotations covering a broad educational experience in all aspects of cardiothoracic surgery, and there is a wide assortment of teaching conferences that the residents are expected to attend.
Education of the residents is accomplished in several important ways. First, much learning occurs from daily contact and interaction with our own faculty and other residents. It cannot be overstated that the program was organized in such a way as to emphasize and to try to take advantage of educational opportunities. Service considerations have been relegated to a secondary position. Physician extenders and administrative support staff provide invaluable assistance in order to free up residents to focus on more important aspects of patient care and to allow more time for educational pursuits.
Second, we have been fortunate to be able to bring to Cincinnati an array of visiting professors during the past few years. They have kindly shared their time and valuable insights with us. In addition, each resident has been given the opportunity to participate in multiple scholarly meetings in order to learn new ideas and techniques and to bring that information back to Cincinnati for evaluation and possible inclusion in our local environment.
Perhaps it is time to ask, "is that all there is to it?" The curriculum and plan for instruction described to this point are necessary, but they are not sufficient. Recall those words of Dr Heuer quoted earlier concerning the acquisition of "a spiritual experience as rich as their surgical experience, which enables them to follow only the highest ideals of medicine." Accomplishing this goal is of the utmost importance and is undertaken through another curriculum. We must instill in our residents a sense of commitment, passion, and pride in their work as well as an understanding of their own vulnerability and imperfections.
The acquisition of knowledge, technical expertise, and experience should be accompanied by the development of wisdom and humility. This other curriculum is focused on empowerment, integration, and transformation. After all, as W.B. Yeats puts it, "Education is not the filling of a pail but the lighting of a fire." If we are doing our job correctly, the residents will gradually understand that the period of residency training is, in large part, all about helping them to develop a clearer understanding of their own personal sense of calling and mission. Maynard Mack puts it well in his book, King Lear in Our Time, in which he posits that the argument of Shakespeare's play, King Lear, is its begging us to seek the meaning of our human fate, not in what becomes of us but in what we become. Or as Dewitt Jones says, "Don't be the best in the world, be the best for the world." We believe this to be our true mission and, by extension, the true mission of every training program. Each program must find its own best methods to accomplish this task, as circumstances vary greatly from place to place. All program directors would do well to consider the sage understanding pronounced in Samuel Antek's description of the great conductor Toscanini; "He did not conduct the orchestra. He conducted the music, and expected us to play it."
Dr Trinkle, whom we remember and honor today, gave the third presentation in this series focused on resident education. In that address he commented on his success as a training program director. He said "the secret: first, you have to give a damn about the people who work for you, and second, you have to show it! Once you establish those two principles, every thing else falls into place" [4]. Although he chose different words to express the secret, it can reasonably be argued that Kent Trinkle understood well what Lytle said, "He knows that instruction carries less weight when the teacher does not love his students."
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