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a Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington
b Department of Surgery, University of Washington, Seattle, Washington
Accepted for publication April 2, 2009.
* Address correspondence to Dr Wood, 1959 NE Pacific, AA-115, Box 356310, University of Washington, Seattle, WA 98195-6310 (Email: dewood{at}u.washington.edu).
Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
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Abstract |
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 Top Abstract IntroductionMaterial and MethodsResultsCommentDiscussionFootnotesReferences |
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Methods: A 38-item survey was designed to assess training, practice, demographics, and relationships of general thoracic and cardiac surgeons. Eighteen cardiothoracic societies representing surgeons on six continents were contacted, and 15 submitted the survey to their membership. The survey was advertised through CTSnet, and 928 surgeons from 105 countries were contacted directly in regions not covered by the professional societies.
Results: In all, 1,520 survey respondents were tabulated, representing 95 separate countries. Non-US respondents were younger, more commonly had practices exclusively in cardiac or thoracic surgery, less commonly obtained general surgery certification, less commonly performed esophageal surgery, and had shorter overall surgical training but longer specialized training in cardiothoracic surgery, although US respondents received greater length of cardiac surgery specific training (all p < 0.05). The US respondents thought that cardiac surgery training was more important for the practice of general thoracic surgery than did non-US respondents, and that it was important for thoracic surgeons and cardiac surgeons to be aligned in public policy and specialty advocacy.
Conclusions: Marked differences in training and certification across the world result in discrepancies in clinical practice, levels of collaboration between cardiac and thoracic surgeons, and culture and attitude differences that are relevant to the feasibility of alliances relating to public policy. These findings also provide important data to inform any decisions about changes in US cardiothoracic training. Greater international cooperation may diminish these differences in order to propagate improvements in cardiothoracic education, and improve patient access and outcomes through shared specialty advocacy.
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Introduction |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionFootnotesReferences |
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To evaluate the similarities and differences between cardiac and thoracic surgeons, a survey was designed to specifically outline the types of training and certification for general thoracic surgeons, looking at the relationship, or lack thereof, between thoracic surgery training and cardiac surgery training around the world.
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Material and Methods |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionFootnotesReferences |
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Eighteen cardiothoracic societies representing surgeons on six continents were contacted, and 15 submitted the survey to their membership (Table 1). The selection of societies to be surveyed was based on geographic diversity, inclusion of general thoracic surgeons in the membership, and with several societies selected because of the dominant membership of general thoracic surgeons. The survey was advertised through CTSnet by a survey notice on the CTSnet home page, in the CTSnet Thoracic Surgery Portal, and in the CTSnet newsletter. Individual e-mail solicitations were made to 928 surgeons from 105 countries residing in regions or countries not covered by the 18 professional societies. Surgeons were identified by country in their posting on CTSnet. In countries with fewer than 30 surgeons, all surgeons were contacted, and in countries with more than 30 surgeons, only those self-designated as general thoracic surgeons were contacted. Survey results were collected over a 6-week period in March and April 2008 and were collated electronically. Participation was anonymous and voluntary. Comparisons were made between US and non-US respondents.
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2 test. |
Results |
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The US surgeons had a median length of training after medical school of 7 years, and 73% had 7 or 8 years of clinical training (excluding research). Non-US surgeons had a median of 6 years of clinical training with a wide distribution of training duration ranging from 4 to greater than 10 years (Fig 1). In contrast, US surgeons spent less time in specialized thoracic or cardiothoracic training than their non-US colleagues (median 2 versus 4 years; Fig 2). The US respondents had a more homogeneous experience in senior level cardiac surgery training, with 96% having at least 6 months of cardiac surgery experience and 75% having 12 months or more. Non-US surgeons were more heterogeneous, with 41% having 6 months or less cardiac surgery training, yet 23% having more than 3 years of cardiac surgery experience (only 5% of US surgeons; Fig 3).
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The US surgeons were board certified in cardiac surgery or thoracic surgery to a greater degree than their non-US colleagues (94% versus 49%, p < 0.001; 95% versus 75%, p < 0.001, respectively), but non-US surgeons were less likely to have a certifying board in their country or region (97% US versus 87% non-US, p < 0.001). Ninety-two percent of US surgeons were certified in both cardiac and thoracic surgery compared with only 38% of non-US CT surgeons (p < 0.001). Forty-eight percent of US respondents thought that their board certification was recognized by most other countries as opposed to 36% of non-US respondents, but a large number of both groups did not know whether their board credentials would be recognized outside of their home country.
Both US and non-US surgeons were most likely to practice nearly exclusively in cardiac or thoracic surgery, as defined as more than 90% practice in one subspecialty area, although this was slightly higher for non-US surgeons (69% versus 77%, p = 0.001). The US surgeons were more likely to have esophageal surgery as a significant component of their clinical practice (55% versus 34%, p < 0.001); and of US surgeons practicing exclusive general thoracic surgery, 88% had a moderate to major practice in esophageal surgery compared with 50% of pure general thoracic surgeons outside of the United States (p < 0.001).
Interestingly, both US and non-US surgeons had similar opinions about the importance of cardiac surgery training for proficiency in general thoracic surgery, with 36% and 38% rating cardiac surgery training as "very important" or "essential" (p = 0.44). Experience with cardiopulmonary bypass, vascular anastomosis, cardiovascular physiology, and great vessel surgery were all believed to be important components of cardiac surgery for the practicing general thoracic surgeon by both cohorts.
The US surgeons strongly believed that cardiac and thoracic surgery were closely allied in areas of public policy, specialty advocacy, and education (81%) whereas only 46% of non-US respondents believed that there was this inter-relationship between cardiac and thoracic surgery (p < 0.001). Likewise, a majority of US surgeons (68%) believed that cardiac surgeons are the best group for general thoracic surgeons to align with in these areas compared with only 44% of non-US surgeons (p < 0.001).
In regard to academics, 60% of US surgeons and 76% of non-US surgeons respondents practiced in an academic institution, including government, university, and community-based academic centers. The median range of reported peer-reviewed publications over the previous 5-year period was 3 to 5 for both US and non-US respondents, and 28% of US and 23% of non-US surgeons reported 10 or more peer-reviewed manuscripts in this period (p = 0.06).
The US surgeons were most commonly members of The Society of Thoracic Surgeons (STS [93%]), followed by the American Association for Thoracic Surgery (AATS [37%]), the European Association for Cardio-Thoracic Surgery (EACTS [13%]), International Society for Minimally Invasive Cardiothoracic Surgery (8%), and Women in Thoracic Surgery (6%). The General Thoracic Surgery Club had 36%, Southern Thoracic Surgical Association had 41%, and Western Thoracic Surgical Association had 21% of US respondents, but the numbers are skewed for these groups as they were the primary sources of distribution for the US portion of the survey. Non-US surgeons were members of the EACTS (37%), European Society of Thoracic Surgeons (28%), STS (24%), Asian Society for Cardiovascular and Thoracic Surgery (12%), Brazilian Society of Thoracic Surgeons (9%), AATS (8%), Japanese Association for Thoracic Surgery (8%), and Society of Cardiothoracic Surgeons of Great Britain and Ireland (6%). Numerous other societies were also represented in this study, but only those with 5% or more member respondents are included here for sake of brevity.
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Comment |
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Individual countries and regions have developed significantly different norms for both the training and practice of cardiac and thoracic surgeons [1–7]. In some countries, cardiac surgery, or frequently cardiovascular surgery, is a distinct specialty with little or no relationship to general thoracic surgery in training, certification, or practice. In others, cardiac and thoracic surgery have varying degrees of relationships in residency training, departmental and practice structure, or in specialty professional societies. In particular, training and certification for general thoracic surgeons varies enormously between countries. For some, thoracic surgery is a subspecialty of general surgery, in others general thoracic surgeons are trained in parallel but separate from cardiac surgeons, and in still others cardiac and thoracic surgery training are united and lead to common certification.
In the United States, training, certification, and practice have remained closely linked. The American Board of Thoracic Surgery (ABTS) has maintained common requirements and certification for cardiac and thoracic surgeons, leading to a high percentage of surgeons in the United States practicing both components of our specialty [8]. Only very recently has the ABTS recognized two different pathways to board certification, with separate index case requirements for a "general thoracic pathway" or for a "cardiothoracic pathway" that were effective as of July 2007 [9]. However, both pathways require significant experience in the corresponding subspecialty, and these still lead to a single set of qualifying and certifying examinations, and a single primary certificate of competence in thoracic surgery.
The ABTS was founded in 1948 and became a primary specialty board in the United States in 1971. From that time until 2003, individuals were required to have certification in general surgery by the American Board of Surgery (ABS) as a prerequisite to certification by the ABTS. Although that prerequisite has been eliminated, a majority of US training programs in CT surgery have continued the traditional pathway of completing a 5-year surgery residency before entering a 2 to 3 year cardiothoracic residency. However, in the past few years, approximately 10% of CT training programs in the United States have added an option known as the 4/3 program that allows a general surgery residency and cardiothoracic residency to share a resident in the fourth and fifth years of training, allowing more focused experience in CT surgery as well as a more seamless transition between the two training programs [10, 11]. Strengths of these programs are that they result in board eligibility for both the ABS and ABTS, allow a tailoring of the general surgery experience toward specialization in cardiothoracic surgery, provide an increase time in CT surgery without an increase in overall training time, and allow identification and recruitment of interested surgery residents at the midpoint of their surgery residency. This last factor, along with the senior general surgery experience, is particularly valuable for residents with a career interest in general thoracic surgery, as these residents usually only become aware of general thoracic surgery as a career choice during their surgery residency, and likewise benefit from the full experience of advanced abdominal surgery afforded the residents in general surgery.
Even more recently, a handful of cardiothoracic training programs have initiated new "integrated" training programs in CT surgery that match residents directly out of medical school and provide a dedicated curriculum in CT surgery for a total of 6 years of training. These programs have the benefit of a shortened overall training time, avoiding the inefficiencies of the general surgery prerequisite that consist of many components that are less relevant to the future CT surgeon. The integrated program is able to recruit interested residents directly from medical school, and allows the CT program director to have total control of the entire training period of the cardiothoracic resident, providing more experience in the increasingly complex management of patients with cardiac and thoracic disease. This program is much more similar to a majority of non-US training programs, with the exception of maintaining combined training in both cardiac and thoracic surgery. The success of our international colleagues and the somewhat analogous historical experience of combined general surgery and cardiothoracic surgery training in the 1970s and 1980s at Duke, Johns Hopkins, and Stanford are proposed as how US training should shift in the near future. The ABTS, recognizing the challenges of training the 21st century cardiothoracic surgeon in only 2 to 3 years, the changes in experience of the graduating general surgery resident, and the lower rate of application to CT training programs, has proposed a requirement that all US training programs change to a 6-year integrated format, more similar to the training provided in most other countries for certification in cardiothoracic surgery.
At present, in the United States the regulations of the Accreditation Council for Graduate Medical Education (ACGME) and the common pathway board certification requirements of the ABTS lead to a fairly homogeneous training for US surgeons practicing either cardiac or thoracic surgery. This is evidenced by a total training time of 7 to 8 years and CT training time of 2 to 3 years by 73% and 86% of US respondents, respectively. Nearly all US CT surgeons have been board certified in general surgery and have board certification in both cardiac and thoracic surgery. However, that comes at a cost of increased training time and yet less cardiothoracic specific training compared with non-US surgeons.
In most of the rest of the world, students enter medical school immediately after secondary school, and as a result, most physicians outside the US start their residency training 2 to 4 years earlier than their American counterparts. Cardiothoracic surgeons outside of the United States have shorter periods of overall training after medical school as well, yet more training time dedicated to cardiac and thoracic surgery. Surgeons outside of the United States had a much more heterogeneous experience in length of training, with 41% training 5 years or less and 15% training 10 years or more compared with 5% and 7%, respectively, in the United States. However, the median total length of training was 1 year shorter for non-US surgeons and the time spent in specialized CT training was substantially longer (89% of US surgeons with 3 years or less, compared with 54% of non-US surgeons with 4 years or more CT training). That would suggest that non-US training may be superior in both efficiency and training of a practicing CT surgeon if time of training is a primary determinant. However, it is important to recognize that only 38% of non-US surgeons are board certified in both cardiac and thoracic surgery, compared with 92% of US surgeons. Although broader board certification may explain why US surgeons have longer training times, this is a paradoxical finding when one considers the more compressed period of specialized training for US surgeons.
Nearly half (46%) of non-US surgeons went directly into a specialized residency in cardiac or thoracic surgery whereas a majority of US surgeons (89%) completed general surgery training before entering CT residency. Yet both US and non-US CT surgeons rarely have a practice constituting more than 10% of general surgery (5% and 13%, respectively). That would suggest that developing more integrated 6-year training programs in the United States, as proposed by the ABTS, may provide the dual benefit of increasing the cardiothoracic specific training time while decreasing the total length of residency, similar to our international colleagues.
Few would disagree that changes and innovation are important in cardiothoracic training programs, given the dynamic advances in our specialty and the changing experience in prerequisite training. At the January 2009 meeting of the Thoracic RRC, the Committee supported further development of 6-year integrated residency programs to recruit interested medical students into the specialty, to shorten the overall length of training, and to provide more focused and specialized training in the components of cardiothoracic surgery. It was recognized that many programs may have the right environment and relationships with general surgery and other allied specialties within their institution to create a robust and unique program to the benefit of their trainees and to the specialty. These programs would subsequently provide experience on the benefits and the unknown liabilities of training US specialists in cardiothoracic surgery directly from medical school.
Although growth in the number of integrated programs appears important for the continued evolution of cardiothoracic training in the United States, it also seems very premature and ill-conceived to make this a mandated change for all US residency programs. As shown in this survey of international differences in training and practice, successful integrated training outside of the US does not necessarily translate to a similar experience inside the US, given major differences in certification and breadth of practice. In fact, if choices regarding overseas training can be interpreted as a surrogate for quality in training, then US training is perceived at a very high level of value by our international peers. Forty-four percent of non-US surgeons trained outside of their country for a portion of their cardiothoracic experience, and one third of those trained in the United States. Yet this number may underestimate the interest in US training, perhaps because of limited access, as 76% of those who did not train overseas would have preferred this experience, and two thirds of them chose the United States as the country of preferred training. Current training of cardiothoracic surgeons in the United States has been very successful, and it would be imprudent to abandon this training in favor of an untested alternative.
Detractors of a mandatory conversion to integrated residencies in the United States raise several other concerns as well. First, US CT surgeons have little or no experience in being responsible for the training of junior level residents, and some program directors may not want to, or may not have the capabilities within their institution of taking control of the total period of residency training. Second, this pathway provides little opportunity for the recruitment of general surgery residents, and undermines the close inter-relationship of general surgery and cardiothoracic surgery that has been a major asset for the training of our residents in the past and present. This may particularly undermine the recruitment of residents interested in general thoracic surgery since these individuals often select cardiothoracic surgery as a specialty that evolves from an interest in upper gastrointestinal surgery or surgical oncology. Third, there is likely a significant attrition rate for medical students entering the specialty, creating unfilled positions that can undermine the residency on one hand, or create opportunities for recruitment of residents from allied specialties as a benefit on the other. Fourth, a sole pathway to CT training essentially eliminates the diversity and flexibility of also recruiting residents within 4/3 combined training programs and traditional 5/2 or 5/3 training programs that have been successful for identifying and recruiting future CT surgeons in the past. Finally, with caps on resident positions in the United States, many programs could find themselves in the dilemma of an "unfunded mandate," that they would have a large number of new resident positions but no institutional funding to support these positions, leading to a Hobson's choice of closing the program or self-funding the new resident positions.
After residency training, cardiac and thoracic surgeons may still benefit from working together and collaborating in areas of postgraduate education and public policy. The combined training in cardiac and thoracic surgery in the United States appears to foster a closer relationship between the specialties. Nearly twice as many US surgeons believed that cardiac and thoracic surgery were closely aligned in areas of public policy, specialty advocacy, and education compared with their non-US colleagues, and this collaboration is likely to produce a synergy of effort that is both more effective and more efficient in these areas. This may provide an opportunity for non-US cardiac and thoracic surgeons to actively pursue ways of working together more closely to best advocate for policy that is important for patients with cardiac and thoracic disease in their own country or region.
Postgraduate education needs are fairly similar across countries and continents, and this is represented by an increasingly international collaboration and attendance at our major cardiothoracic surgery meetings worldwide. Although public policy issues are substantially different from country to country, there are still significant similarities that may benefit from shared experience and ideas between cardiac and thoracic surgeons, and between US and non-US surgeons. This collaboration has been initiated by joint leadership meetings of the executives of our major international specialty societies, but is still fledgling in its development and is worthy of more concerted efforts to learn from each other's experiences and to support each other's agendas in education and policy.
The US surgeons and non-US surgeons have many similarities, but also many differences. Cardiac and thoracic surgery are much more closely intertwined in the United States, and that may be partly responsible for longer and less efficient training. However, the increasing diversity of US training is a logical response to this deficit and benefits from retaining the strength that exists in US training today. Integrated 6-year residencies add to this training diversity in the United States, but mandating this pathway as the sole route to ABTS certification will undermine the advantage that we have in our current training and in the breadth of options available for prospective cardiothoracic surgeons in the United States. Cardiac and thoracic surgeons, and US and non-US cardiothoracic surgeons should strive to work together to optimize our continued educational challenges and to best effect public policy on behalf of patients with cardiac and thoracic disease.
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Appendix |
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Training and certification for general thoracic surgeons varies enormously between countries. For some, thoracic surgery is a subspecialty of general surgery, in others general thoracic surgeons are trained in parallel but separate from cardiac surgeons, while in others cardiac and thoracic surgery training are united and lead to common certification. This survey's goal is to outline the types of training and certification for general thoracic surgeons, and specifically looking at the relationship, or lack thereof, between thoracic surgery training and cardiac surgery training around the world. This should only require 5-10 minutes of your time. Responses will remain confidential. Thank you for taking the time to answer these few questions to help us understand our specialty better.
100% general thoracic surgery 100% cardiac surgery More than 50% general thoracic surgery combined with cardiac surgery More than 50% general thoracic surgery combined with general and/or vascular surgery Less than 50% general thoracic surgery combined with cardiac surgery Less than 50% general thoracic surgery combined with general and/or vascular surgery I do not practice general thoracic surgery (STOP: it is not necessary to complete the rest of the survey) 100% general thoracic surgery 100% cardiac surgery More than 50% general thoracic surgery combined with cardiac surgery More than 50% general thoracic surgery combined with general and/or vascular surgery Less than 50% general thoracic surgery combined with cardiac surgery Less than 50% general thoracic surgery combined with general and/or vascular surgery I did not practice general thoracic surgery 5 years ago I was in training
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General Surgery Training and Certification
Yes No Yes No Yes No
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General Surgery and Esophageal Surgery
0-10% 11-30% 31-60% 61-80% >81% 0-10% 11-30% 31-60% 61-80% 80-90% >90% I have a major practice in esophageal surgery and my colleagues and I perform the majority of esophageal surgery in our hospital I do a moderate amount of esophageal surgery although my colleagues and I perform the majority of esophageal surgery in our hospital I do a moderate amount of esophageal surgery because several different specialties and groups all perform esophageal surgery at my hospital I do very little esophageal surgery because several different specialties and groups all perform esophageal surgery at my hospital I do not do esophageal surgery Predominately general thoracic surgeons A combination of general surgeons and general thoracic surgeons Predominately general surgeons
separate period of additional training after completion of general surgery training? specialized program in thoracic surgery that you entered after medical school or after a limited (2-3 year) period of core surgical training? for a practice of general thoracic surgery only? for a practice of general thoracic and cardiac surgery? for a practice of general thoracic and general and/or vascular surgery? 4 years 5 years 6 years 7 years 8 years 9 years 10 or more years No specialized training period 1 year 2 years 3 years 4 years 5 years 6 years 7 or more years Yes No Yes No To learn new techniques To obtain research experience To increase my reputation or job opportunities at home To wait for a job opening at home To increase the options for job opportunities outside of my home country To strengthen my technical skills
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Cardiac Surgery Training for Thoracic Surgeons
Yes No 0-3 months 4-6 months 6-12 months 12-18 months 18-24 months 25-36 months 37-48 months Greater than 4 years Not at all important Moderately important Very important Essential Not at all important Moderately important Very important Essential Cardiopulmonary bypass Vascular anastomosis Cardiovascular physiology Experience with great vessel surgery Yes No
Yes No Yes No Yes No My training and certification is recognized in most other countries My training and certification is recognized in some countries, but I would have difficulty being able to practice thoracic surgery in most countries My training and certification is not recognized in most countries and it is unlikely that I could practice thoracic surgery outside of my country I do not know
Yes No I don't know Cardiac surgeons General surgeons Vascular surgeons We do not need to align with others and are best served by working predominately for ourselves without other alliances I don't know
<30 years 31-40 years 41-50 years 51-60 years 61-70 years >70 years Male Female I am still in training 0-5 years 6-10 years 11-15 years 16-20 years 21-30 years >30 years 0 1-2 3-5 5-10 10-20 >20 Academic, university-based hospital Academic, community or private hospital Academic, government hospital Private practice, community or private hospital Private practice, government hospital 
American Association for Thoracic Surgery Asian Society for Cardiovascular and Thoracic Surgery Australasian Society of Cardiac and Thoracic Surgeons Belgian Association for Cardio-Thoracic Surgery Brazilian Society of Cardiovascular Surgery Canadian Association of Thoracic Surgeons European Association for Cardio-Thoracic Surgery European Society for Cardiovascular Surgery European Society of Thoracic Surgeons French Society for Thoracic and Cardiovascular Surgery General Thoracic Surgical Club German Society for Thoracic and Cardiovascular Surgery Indian Association of CardioVascular-Thoracic Surgery International Society for Minimally Invasive Cardiothoracic Surgery Israel Society of Cardiothoracic Surgery Japanese Association for Thoracic Surgery Korean Society for Thoracic and Cardiovascular Surgery Mexican General Thoracic Surgical Club Netherlands Association for Cardio-Thoracic Surgery Philippine Association of Thoracic and Cardiovascular Surgeons Polish Society of Cardio-Thoracic Surgeons Scandinavian Association for Thoracic Surgery Society for Cardiothoracic Surgery in Great Britain and Ireland Society of Cardiothoracic Surgeons of South Africa Society of Thoracic Surgeons Southern Thoracic Surgical Association Spanish Society for Thoracic and Cardiovascular Surgery Swedish Association for Cardiothoracic Surgery Turkish Society of Cardiovascular Surgery Western Thoracic Surgical Association Women in Thoracic Surgery World Society of Cardio-Thoracic Surgeons |
Discussion |
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So I want to congratulate you and say that the European Society of Thoracic Surgeons would be very glad to join this international cooperation you are asking for, to try to organize these similar training programs around the world, as you have just shown to us, and to try to copy the good things you have here and perhaps some things that we have been done in Europe. Thanks, Doug.
DR WOOD: Thank you Laureano, and I will take this opportunity to thank the European Society of Thoracic Surgeons for great participation and cooperation in this survey. You guys were leaders and very helpful in getting this done.
And likewise, although I think there is something to learn in Europe and in other parts of the world from how things are done in the United States, part of my point here is there's also quite a bit to learn in the United States from our colleagues in Europe, Asia, South America, and to some degree in Africa, although there is less thoracic surgery involvement in Africa. But there's a lot for us to learn from each other all the way around, and that's the goal of trying to improve these collaborations.
DR MATTHEW W. SCHOOLFIELD (Portland, OR): I'm currently a fellow. The question would be, do you see in the future as a fellow that we would have access to other programs where they're doing other procedures that we may not have at our home institution and just have support about going back and forth, either spending a month one place or another to pick up, say, percutaneous catheter-based skills and things if we can't find that at our own institution? Is there a move to go in that direction?
DR WOOD: Yes, that's a good question. I wouldn't say there's a move to go in that direction, your last question, but there very clearly is that opportunity in several kinds of ad hoc ways. It's mostly things that would be individually developed, and there are mechanisms for doing that.
The Thoracic Residency Review Committee does allow for short, limited experiences outside of your home institution. There are sometimes service demands at your home institution that interfere with that ability, but we try to not let that be the priority.
And also, there are scholarships. Actually, at the University of Washington last week, we had a fellow from another training program traveling on an AATS traveling scholarship to come to Seattle to spend ten days to learn a set of procedures that were not common in the home institution. So, yes, those opportunities are currently available, but they are really individualized.
DR PETER P. MCKEOWN (Pikeville, KY): Doctor Wood, firstly, a great topic and certainly something we need to focus much more on. If I could just follow up a bit from the last comment and talk about other education opportunities and maybe tie into what Dr Feins has dealt with in regards simulation centers.
There are a couple of centers around the country specific for procedures. For instance, there is a spine center in Chicago where a multicollaborative group, have gotten together for specific procedures and have established essentially have a beautiful training center. And there's a similar one, of course, in Memphis. I wonder if there is an opportunity for the Society to develop some of these types of training centers. Some of it would be cadaver based. Some of it would be simulation based.
But it might answer that question where can, not just the trainees, but also perhaps surgeons who've been out in practice and want to be retrained, go to learn a new procedure. I wonder what your thoughts are about that?
DR WOOD: Well, those are great ideas and, fortunately, ones that have been considered and thought about by the leadership of all of our Societies. And I really think it's that point that you've raised and the lack of any kind of centralization that has resulted in the creation of the Joint Council of Thoracic Surgery Education. This provides a substantial commitment of resources and dedicated staff to help organize those types of simulation or centers of developing specific skills to augment and to assist our current training programs.
I think that we are on the cusp of this being very dynamic in cardiothoracic surgery, and I would expect within the next year or two that we will see a substantial use of those resources like the boot camp that occurred this past summer.
DR PAOLO MACCHIARINI (Barcelona, Spain): Doug, I like it very much, and I congratulate you because this is the first, I hope, attempt to provide evidence that we are not doing well by training residents and fellows. And I'm speaking for Europe. I cannot speak for this country.
But this is the statistic, and this is far away from the reality. It's not a question. It's a comment. We do not need to change the training programs. We need to change the brain of those who are responsible for that program if they don't teach the young ones to do surgery. And surgery means not doing a lobectomy or pneumonectomy, but whatever it is, general thoracic surgery. And this is not done in most of the European countries.
I worked in Paris. I worked in France, in Germany and Italy and in Spain, and I can confirm for you that this is not the case. There is no training program. You just start day 1 till day 31 December after 5 years. But the majority of the residents and the fellows, they even cannot do a thoracotomy or a lobectomy or a pneumonectomy. And I think that this should be said because this is the truth, and this is what we need to change. Thank you.
DR WOOD: Thank you, Paolo, and you're right, that when we get down and dirty about what's really happening in training programs, it's often discouraging. And I'll say although I think it's better in the United States than what you're describing, that's largely because of better regulation.
I think a strength of the United States is that we are more homogenous. We have an ACGME with a residency review committee that really forces cardiothoracic surgeons to be better educators than they otherwise might be. And I think many countries in Europe don't have that level of oversight, and actually, I, frankly, think we would be no different in the US if we didn't have that oversight. Nonetheless, there is a lot of educational heterogeneity in the United States and outside of the United States. And one of the efforts of the Joint Council is going to be to try to develop champions in the training programs, each of our training programs, who are newly renewed and dedicated to the excitement of educating residents and trying to improve our educational system.
It would be great if we can take any of the things that we learn in that process in the United States and can share that with any of our colleagues elsewhere in the world that may want to have the same benefit of that enthusiasm and that renewed dedication to teaching. Thank you very much.
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Footnotes |
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* See note at end of article regarding e-only Appendix. 
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This article has been cited by other articles:
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  A. T. Pezzella Global Aspects of Cardiothoracic Surgery with Focus on Developing Countries Asian Cardiovasc Thorac Ann, June 1, 2010; 18(3): 299 - 310. [Abstract] [Full Text] [PDF]
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 D. E. Wood and F. Farjah Training, certification and practice of cardiac and thoracic surgeons in Europe: a comparison of the members of the European Association for Cardio-Thoracic Surgery and the European Society of Thoracic Surgeons Eur J Cardiothorac Surg, March 1, 2010; 37(3): 511 - 515. [Abstract] [Full Text] [PDF]
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