Look at Our Past and Challenge Your Future with Clinical Excellent and Commitments to Discovery and Innovation

I’m really happy to have this opportunity to communicate with current Thoracic Surgery Residents--those in programs at this time, as well as those matched to residency positions for the upcoming year.  I hope that some of the general surgery residents and med students who might be considering a career in Thoracic Surgery will be among those who read these comments and consider my perspective on what may be in the future for Thoracic Surgery.  It’s not that I am so sure that my predictions are that correct, but I am convinced that all of us in Thoracic Surgery must carefully reflect on the current state of the specialty and participate in planning for the future of Thoracic Surgery.  We must engage those evolving factors that will determine what the future will turn out to be.  It is critical, as well, that we empower our young colleagues, including those in residency programs and training, if we hope to have a productive future and achieve the full potential of Thoracic Surgery in decades to come.

With my Johns Hopkins background, based on years of residency training and service as a member of the faculty there, my own initial perspective on the exciting origins of Thoracic Surgery is personified by Alfred Blalock and his accomplishments in treating children with Tetralogy of Fallot.  Most of us senior Thoracic Surgeons have one or more direct connections to early leaders in Thoracic Surgery, such as Churchill, Graham, Alexander, Bigelow, Hufnagel, Kirklin, Lillehei, along with others including Shumway, Grillo, Pearson, Carpentier, Yacoub, Castaneda, and many others too numerous to mention but far too important not to acknowledge. The heritage of our specialty is truly remarkable, starting just over 80 years ago with those early pioneers who dared to venture inside of the chest, followed by more recent pioneers, many of whom are still with us, who took on heart and vascular, lung, esophageal and airway conditions that most “experts” believed to be untreatable.  Thoracic Surgery today has become so successful that other medical practitioners and the public expect us to be successful, no matter how formidable the surgical challenge.  Many in our society have come to expect that any outcome other than complete success must be explainable by some error or mistake during the procedure.  As seems to occur so often in the most complex of human endeavors, our successes have bred assumptions of invincibility.

Thoracic Surgeons know well that the successes of our specialty have been built on innovation, brilliance, clinical daring, very hard work and, especially, commitment to excellence in problem-solving and execution.  As the specialty has matured in its scope and accomplishments, expectations are that we perform our work flawlessly, despite the complexities involved, each time a patient is taken to the Operating Room.  The era of the “ward patient” who was there for surgical residents to manage independently ended in the U.S. when the Medicare program commenced, and the ill-conceived way of training resident surgeons that arose during the height of “charity medicine” has no contemporary justification.  Remnants of socio-economic, racial or ethnic disparities in health care effectiveness cannot be justified by the need to educate and train young physicians and surgeons.  Surgical resident training today must be based on the apprentice model, where the ultimate responsibility for the patient and his or her surgical treatment remains in the hands of the attending surgeon.  Like the recent implementation of the 80-hour work week for surgery residents, so well discussed by John Calhoon in his recent New Horizons essay, the current definition of the resident’s role as apprentice rather than principal surgeon can be very effectively integrated into residency training with committed faculty.  The primary negative consequence is likely to be the need for even longer time periods for adequate resident training.  Regardless, it is ethically compelling to insure that surgery residents are properly supervised and mentored, and that they are physically and mentally fit to participate safely in patient care.  I mention this now because I believe that the undeniable principles of proper patient care and appropriate expectations on residents’ time and efforts will further alter the future of Thoracic Surgery by requiring substantial changes in the ways in which we train Thoracic Surgery residents, including the length of specialty resident training.

At the present time, many Thoracic Surgery residents receive a bare minimum of truly adequate training and clinical experience, especially in some of the most challenging aspects of the specialty, such as esophageal resection and reconstruction, thoracic aortic surgery, neonatal heart surgery, and so on.  We compensate for these limitations in residency experiences by adding on post-residency fellowships and other training experiences.  What we have not been willing to do is to shorten the pre-Thoracic Surgery residency and training periods that are still based on the requirement to become a certified general surgeon.  Like most Thoracic Surgeons, I found my five years as a general surgery resident at Hopkins to be valuable.  In fact, some of those experiences, such as time spent on the renal transplant service in the early 1970s, were enriching and highly influential on my clinical and personal growth.  But much of time spent in the general surgery residency, as useful and interesting as those experiences may have been, would have been more effectively spent preparing me for a career as a cardiothoracic surgeon if I had spent more of those years on Thoracic Surgery and closely related services.  I believe that so much time and effort is expended preparing oneself for one’s principal career activities, with long years in college, medical school, general surgery, time spent in research settings and/or military service, that what could be the peak performance years for Thoracic Surgeons, are taken up by extended and unnecessarily long periods of training.  Technically demanding surgery such as we do in today’s Thoracic Surgery requires physical strength and endurance while at the same time technical adeptness and clinical judgment are essential.  Are we at our best as surgeons when we are in our 30’s or 40’s, or in later years?  I’m not disparaging the immensely important contribution of experience and the refinement of clinical judgment that is based on greater time spent as a surgeon.  Nor do I suggest that a surgeon in his 60’s or even 70’s is necessarily limited.  But I do believe that we might see even greater accomplishments, innovations and surgical developments by our rising Thoracic Surgery leaders if these young surgeons got started in their independent careers earlier and with more direct experience in Thoracic Surgery specialty areas.

To summarize those changes in Thoracic Surgery training that, I believe, are inevitable, necessary and overdue, there must be substantial modification in the distribution of time spent preparing an individual for a career as a Thoracic Surgeon.  The ever-increasing complexity of Thoracic Surgery and the concomitant increase in the surgical challenges that we face demand that more time be spent in Thoracic Surgery-specific training.  Although the general surgery years have provided us with preparatory clinical and surgical skills, as well as the maturity and seasoning, these experiences can be obtained in more appropriately focused ways. We must insist upon better time utilization in the training and education of the Thoracic Surgeon of the future lest we continue to begin our independent professional careers well into middle age.  We may be squandering some of our most promising years as technically adept and innovative surgeons.  In addition, despite what some stalwart and long-suffering current and recent residents state, the length of education and training to achieve full competence and independence as a Thoracic Surgeon today, is a disincentive to many who would consider a Thoracic Surgery career but are unwilling to postpone their careers until middle age.

Let’s assume that we do alter the historical model of Thoracic Surgery education and training in a way to allow our residents and young colleagues to enter the specialty with more Thoracic Surgery-specific experience at younger ages.  Isn’t the future scope of practice in Thoracic Surgery an even more fundamental question and problem?  Isn’t this where the real challenge exists when talking about “New Horizons” in Thoracic Surgery? Is there, in fact, a real future for the specialty?  Let’s take a look at the future, but with an eye on the past history of the specialty and an even clearer understanding of how biomedical science and medicine have evolved.

Much of the angst in the specialty today is a result of declining cardiac surgical activity.  The current reduction in demand for coronary artery surgery likely will  continue, although perhaps at a less dramatic rate of decline than seen over the past 5 years.  In addition, catheter interventions for some valvular heart conditions, although likely to be less effective than established surgical treatments, will be promoted by interventional physicians and will be embraced by patients who will accept less definitive or less effective treatment in order to avoid major surgery and its risks.  Very few individuals choose a major invasive operation when a plausible option exists.  We are wasting our time and energy if we insist that patients should ignore, for example,  the prospect of having one’s coronary artery disease effectively treated with a catheter intervention rather than with the traditional sternotomy approach.  All of us know Thoracic Surgeons who have been effectively and perhaps definitively treated with a percutaneous catheter intervention and who chose that route despite what is written in our literature about conventional CABG being “the gold standard.”  The challenge shouldn’t be framed in terms of surgeons defending a traditional “standard” against the infidels who are challenging that standard.  The real issue is that there has been astounding progress in catheter-based therapies for coronary artery disease and many people with CAD who required bypass surgery in the past can now be treated successfully with stents and with less personal disruption, pain, expense and even risk.  Sure, it is clear that many PCI proponents do not acknowledge the limitations of PCI and are unwilling to consider that the “competing” option of surgery would be a better course for a given patient.  And, yes, we must insist on scientifically rigorous follow-up assessment and comparative analysis of new therapies, both interventional and surgical, to insure that decisions for medical, interventional or surgical treatments are appropriately identified and presented for the patient’s consideration.  But we should not and cannot allow Thoracic Surgery to be viewed as anti-innovation and opposed to obvious therapeutic advancements as they emerge.  Vascular Surgeons are facing the same hard facts and may be ahead of us in adopting and integrating catheter and less invasive options in place of some traditional vascular surgical treatments.

The process of evolution in medical practice has been both fascinating and highly complex.  What made the Blalock shunt such a compelling development was the lack of any effective way to treat children with cyanotic congenital heart disease.  When more definitive open heart surgical repair options became available, an interesting but predictable dilemma was experienced by Helen Taussig and her pediatric cardiology colleagues at Hopkins who frequently were reluctant to refer their patients with failing or inadequate Blalock shunts for open repair, preferring the limited prospects of systemic-pulmonary shunt to the more promising but much riskier complete open repair on cardiopulmonary bypass. What would have happened to surgery for congenital heart disease if surgeons acquiesced to the cardiologists’ anxieties about putting their declining patients at risk for more complete and effective treatments?  What would be the current state of abdominal surgery if the “young Turks” who have evolved into members of SAGES  (Society of American Gastrointestinal Endoscopic Surgeons) had not pushed for laparoscopic cholecystectomy despite such early problems of bleeding and common duct injuries?   What about OPCAB surgery for CAD patients?  We can agree that it is still unclear that beating heart CABG is safer than and as effective as conventional CABG in all situations, but would we want the traditionalists among us who choose not to perform OPCAB to inhibit those who can perform it safely and reliably and believe it is preferable for some patients?

As discussed above, Thoracic Surgeons today are expected to perform flawlessly.  This level of public expectation, which has been almost unique to cardiac surgery but is now affecting other physician groups and health care more widely, forces us to be cautious and even conservative in promoting new therapies.  But we have to distinguish between the need for excellence with and refinement of established therapies versus the critical need for medical innovation and the development of better therapeutic options.  There is much to learn from the oncology area.  While safety and clinical excellence of procedures and treatments such as the Whipple procedure, triple agent chemotherapy, and aggressive radiation therapy protocols are demanded, the most respected oncologists are also expected to be at the leading edge of cancer diagnosis and therapy.  Extent of participation in clinical trials has become a surrogate for excellence in oncology programs. Access to new therapies is a determinant for many when choosing an oncologist.

So, what are the “New Horizons” in Thoracic Surgery?  How will the specialty look in 5, 10 or 20 years?  I need to start with and stress some caveats: 1st, my personal experience has been as a cardiac surgeon and I simply can’t credibly predict specific horizons in general thoracic surgery. 2nd, even in the cardiac surgery area, I can only guess about what those specific areas, or new horizons, will be.  But, as I said earlier, I can make some educated predictions based on the history of the specialty and trends that I see in contemporary cardiac surgery. I also can refer you to the report of a recent NHLBI-sponsored Working Group that considered the future of cardiac surgery research (1).  3RD, whatever predictive value I might have to offer is based more on my understanding of what the specialty must do to enable Thoracic Surgeons to continue to be leaders in innovation and evolution than on specific surgical or programmatic initiatives.

Also, lest we allow ourselves to believe that declining CABG volume reflects actual decline in the accomplishments and scope of  current cardiac surgery, let’s review some of the exciting things that have been going on during the past decade or two.  Over the past 2 decades, the refinements of the Maze-Cox approach for the treatment of atrial arrthymias have been remarkable. It appears now that the Cox-Maze 3 or 4 (any procedure qualified with that many versions is probably still in evolution) has been established as the most reliable and effective procedure for dealing with atrial fibrillation.  The fact that this disabling but not life-threatening condition (atrial fib) is believed by few cardiologists and potential patients to warrant such a major operation is not a reflection of the procedure’s importance. It is the benchmark or “gold standard” against which the “mini-Maze” and catheter-based therapies should be judged.  In the CABG area, beating heart CABG has been the big event, not quite as influential as the demonstration of improved efficacy when an internal mammary artery graft is used, but even more provocative in prompting a paradigm change in CABG surgery.  In the valve surgery area, while only modest modifications of synthetic valve substitutes have emerged recently, the success of mitral valve repair surgery has been the major advance in the past decade and has raised the bar for all cardiac surgeons.  Other valve repair or sparing procedures, importantly, are in evolution.  The emerging prospect of percutaneous options for valve repair, both mitral and aortic, highlights one of our most important challenges for the future, the requirement for surgeons to re-enter the catheter intervention area.  The development of less invasive surgical approaches to valve repair and replacement also has been an important advance and will require continued refinements and wider adoption.  In the heart failure area, ventricular reconstruction procedures and more options for mechanical ventricular assistance, including the possibility of destination VADs, have been major steps forward.  In thoracic aortic surgery, endograft options are rapidly emerging, and the formation of multidisciplinary teams has greatly improved the scope and safety of major thoracic aortic surgery procedures.  In congenital heart surgery, it was common 15 years ago for the parents of infants with single ventricle anatomy, especially hypoplastic left heart syndrome, to be offered the option of “compassionate care” for their infants—in other words, there would be no surgical intervention.  Today, many congenital heart surgery centers are achieving routine success in managing infants and young children with these conditions using staged, safe and effective surgical procedures.  Similar examples abound in all areas of Thoracic Surgery.  In other words, while the specialty has matured in many areas, there continues to be plenty of progress and new developments, both currently and on the horizon.

So, what will determine our future as Thoracic Surgeons?  First and foremost, we must continue to be surgically and clinically as flawless as possible.  Patients will not, and should not, submit themselves to surgical care unless we and our associates are technically and surgically expert at what we undertake.  John Calhoon’s New Horizons essay alluded to the transformation of single-individual responsibilities in medicine to team models.  I agree wholeheartedly, but the Thoracic Surgeon will always be the team leader, relying on others, but assuming the ultimate responsibility.  Yes, there will still be errors of commission and omission, even errors on the part of the surgeon, but it is our responsibility to insist that our surgery teams and systems are as well designed as possible.  What about the issue of variations of talent or performance capability by individual surgeons?  How can we expect “perfection” (flawless performance) from all?  We must, I believe, insist upon higher standards in training programs for certification and on-going maintenance of certification.  Our trainees need more specific training time and greater apprentice-style mentoring in Thoracic Surgery, with less time spent in preliminary education and general surgical training.  We also must be willing, as program directors and leaders in the specialty, to redirect those who aspire to Thoracic Surgery but are not intellectually, technically or psychologically suited for this very difficult career. 

We also need to empower our younger colleagues to be inventive and innovative.  In the history of our specialty, it was virtually always the younger surgeons who made things happen, the young Lillehei, Shumway, Kirklin, Starr, Cooley, Carpentier, and many others.  More recently, it was the young Joel Cooper and Bruce Reitz who were responsible for successful lung transplantation, with the support of their colleagues and with the direction and empowerment of their mentors.  I agree that it takes a host of others to refine and propagate those developments, and that for most of us, refinement and improvements of someone else’s operation are more likely to be where we contribute to the development of the specialty.  But just as the remarkable team of Blalock residents and trainees built much of the next generation of early heart surgery from the inspiration and excitement that was created at Hopkins by the blue-baby successes, we must foster that kind of attention, empowerment and excitement among our young associates.  One of my closest friends in Thoracic Surgery, a brilliant and, himself, an innovative surgeon who has mentored some of tomorrow’s leaders, could be even more effective in promoting the future of the specialty by being less critical and more responsive to the excitement and ideas, even off-the-wall ideas, of his young colleagues.  Our specialty can’t rest on the laurels and accomplishments of our acknowledged leaders.  There are relatively few effective innovators past age 50.  If we allow our specialty to be dominated by our leaders of the past, as significant as they have been to past progress in the specialty, the future will be quite limited. 

So, my advice and perspective for our young colleagues:  The future is in your own hands and you must grasp it.  Become as technically and clinically adept as possible.  Until the specialty sorts out the most effective training pathways to Thoracic Surgery certification, insist that you receive excellent training as a surgeon.  If you emerge from residency training without the scope or confidence that you need to take on your chosen area of contemporary Thoracic Surgery, find yourself a situation where early career mentoring and support are possible.  The apprentice model should extend into your early years as an independent certified surgeon, but don’t allow yourself to become an indentured worker for senior surgeons who are not supportive of your future and that of the specialty.  Not every one of us has the imagination or talent to create new hypotheses or technical advances.  And, in fact, some Thoracic Surgeons, who have had the greatest aptitude for innovation, have lacked the clinical or surgical skills to accomplish all that was possible from their new ideas or techniques.  Most of us contribute to innovation in the field by improving and enhancing the new technique or device.  What is just as critical to progress in the specialty, however, is for most or all of us to support innovation, be perceptive in determining what is potentially better, and to be cautious adopters despite the effort and challenges involved.

In closing and reflecting on what has been a most satisfying professional career for me in Thoracic Surgery (I really liked my job!), I must acknowledge that it is a very demanding career.  One of my early advisors at Hopkins, an excellent and thoughtful cardiac surgeon at the time, told me, when I asked his advice about whether to pursue a career in Thoracic Surgery, “Don’t take on a career in cardiac surgery unless it is the only thing in life that will make you happy.”  While clearly this was an exaggeration even about how he viewed his life in Thoracic Surgery, he did make the point to me, loud and clear, that Thoracic Surgery is not for the faint of heart.  This is even more so today than it was back then, when elective CABG surgery dominated our OR schedules.  But what his advice does suggest, especially today, is that Thoracic Surgery is an elite career, with remarkable predecessors and a tradition of innovation and superb patient care.  Based on those who have preceded us and the culture of excellence in the specialty, we Thoracic Surgeons of today and even more importantly, you Thoracic Surgeon leaders of the future, must sustain that tradition and further the culture of accomplishment and excellence that has always defined the specialty.  Embrace change and promote innovation.

References

1. Baumgartner WA, Burrows S,  del Nido PJ.  Recommendations of the National Heart, Lung, and Blood Institute Working Group on Future Direction in Cardiac Surgery. Circulation 2005;111:3007-13.