Mentors Are Needed

We are pleased to present to our readers an exchange of letters (in the modern format of emails) between a fourth-year medical student from Singapore and one of our most distinguished senior cardiothoracic surgeons. The letters bring up numerous important points. Perhaps the most important point is that mentors are needed in order to provide guidance, inspiration, and motivation to young students and residents who aspire to a career in cardiothoracic surgery. Mentorship can take many forms. This exchange points out that sometimes it can be accomplished quite simply by responding in a thoughtful and encouraging manner to inquiries from young persons seeking information and guidance. Perhaps you will think of additional ways in which you might provide mentorship, and perhaps you will be willing to do so. Opportunity abounds.

Walter H. Merrill, MD
Division of Cardiothoracic Surgery
University of Cincinnati
Cincinnati, OH, USA 

Dear Sir,
 
Allow me to introduce myself. My name is Ashok, and I am a 4th year medical student from National University of Singapore. As I was browsing through the pages of CTSNet (as I often do) I came across your article "In my opinion, we need an attitude adjustment." It was an excellent read and inspiring in a way. 
 
I have been fascinated with cardiac surgery ever since my 1st year in medical school. I got myself attached to a heart surgeon and spent time with him in the operating room 2 months into medical school. I was hooked. I started spending more time in adult as well as in pediatric heart surgical units over here in Singapore as well as in India. I loved the nights I spent in the Cardiothoracic ICU outside my main medical school curriculum. Sadly, to every resident that I expressed my interest in cardiac surgery, every single one of them dissuaded me from entering a specialty which they simply termed as "dying". Many advised me to take up cardiology instead. I have spent elective time in cardiology units, but I just don’t dig it as much as cardiac and thoracic surgery. 
 
So, you were right in the article, few residents are entering into this specialty with the passion that the previous generation of cardiothoracic surgeons had. We need to do something to correct that. The long hours throw people off, but there is a beauty in "stopping a heart, fixing it, and starting it again".  That still inspires some of us. But sometimes, the dissuasion that I get from residents training in cardiothoracic surgery throws me off.  I am often left wondering whether I should stick to my passion or to give it up and choose a specialty that has a more predictable future. For the specialty to still be able to attract the best, we have to increase interest by illustrating the beauty in it, not by telling young medical students and residents what they can gain from it in terms of prestige or monetary rewards. We need to encourage people who show interest in it at a young age,  such as medical students, not PGY-5 residents. We need  training programs which incorporate catheter based interventions as well. 
 
These are just some of my thoughts. Thank you for that thought-provoking article of yours. I look forward to hearing from you.
 
Warmest regards,
 
Ashok Venkataraman
4th-year medical student
National University of Singapore
Singapore

Dear Ashok,

What a great letter! Thanks so much for your thoughts and insights into this growing problem.  For some time now I have received encouragement to write something that would might inspire young people to consider cardiothoracic surgery. Your letter says it all, so with your permission I would like to publish it along with my response to a few of your thoughts.

As far as attracting young people to our specialty we need to first answer the question "What draws any of us to medicine as a profession?"  The opportunity to serve was, and surely still is, the most powerful attraction for the vast majority of us.  Even with the advent of health care "delivery" systems (a phrase I despise), medicine is still a very individual, personalized profession.  One can understandably take pride in participating in public health endeavors that impact large populations.  However, for the majority of us, the customized service we provide one-on-one to our individual patients produces a sustained level of personal satisfaction unrivaled by virtually any other endeavor.  
 
Cardiothoracic surgery simply takes this satisfaction to another level. As you point out, there is ultimate beauty in what we do. Our patients literally put their lives in our hands, and with our hands, we impart the accumulated wisdom and skill of our discipline. When he was in his 90s, a great pianist was asked why he continued to give concerts to large crowds.  He responded that he could not imagine anything that would be more rewarding than being able to give so many people so much pleasure with his own hands.  That's the part we are liable to lose sight of in the malevolent maelstrom of Medicare and other managed care schemes, i.e., the pure satisfaction derived from hands-on service.
 
Is ours a "dying" specialty as some of your colleagues suggest?  I asked the same question some years ago in an address to the Society of Thoracic Surgeons (Annals of Thoracic Surgery 1995;59:1047-55).  My conclusion, then and now, is a resounding NO.  If for no other reason than the leading causes of death in men and women continue to be heart disease and lung cancer.  "Statins" notwithstanding, I am afraid these problems will be with us well into the foreseeable future. 
 
Does that mean we do not need to regularly reexamine where we are and where we are going in the practice of our specialty? Of course we do! For example, we need to look at your suggestion that our training programs incorporate catheter-based interventions.  Just how we introduce that (really reintroduce since originally surgeons were very active in that arena) and other innovative ideas is something with which we all struggle.  In that same address to the STS I suggested we work toward developing a specialty that combines our knowledge and skills with the cardiologists.  The hope behind that suggestion was that patients would benefit from having a multitalented physician without a particular ax to grind.  When treatment options presented themselves, the solution would more clearly be based on what is best for the patient rather than what do I do best, as it too often is at the present.
 
The clinical challenges faced by cardiothoracic surgeons are of growing complexity yet they still give way to clear thinking, and that is appealing to many who enjoy problem solving.  We are presented with problems that yield to rational analysis and artful application of our skills.  By far the greater number of our cardiac patients are directly and immediately benefited by our ministrations. Even the twin troublemakers, lung and esophageal cancer, are beginning to respond to modern thoracic treatment techniques.  Ours is an exciting and gratifying specialty.
 
And, as you suggest, it has a beauty that is unsurpassed. The anatomy is spectacular and the physiology fun to explore.  The mastery of the necessary skills is challenging but totally absorbing once fully engaged.  The problems presented to us and the possible solutions are varied enough to hold our attention.  And our contribution is life changing. What more can one ask?
 
Two other aspects of our specialty that merit consideration are the exciting new techniques that are available to us and the opportunity to be a part of a team of professionals working for our patients’ welfare.  Thoracoscopic techniques, off pump CABG, minimally invasive valve surgery, not to neglect transplantation and artificial organs, all challenge us in a most positive way.
 
We are also sometimes "stretched" by our interdependence with other disciplines.  Yet, some of my most gratifying times in practice were when I was working successfully with dedicated colleagues in other fields to address the needs of our patients.  Successful practice of this sort can require an "attitude adjustment" on all of those involved, but there is really no alternative if we want to be of service.
 
You are right on target when you say we need to get this message to medical students and young residents.  Our best studies (Ann Thorac Surg 1993;55:1303-10, reprinted from The Annals of Thoracic Surgery with permission from The Society of Thoracic Surgeons. All rights reserved.) show that individuals make the decision to go into thoracic surgery early in their residency training.  Also, it is true, as in your case, that the single most important factor influencing their choice is the attention of a mentor.  That's why the "attitude" of our Thoracic faculties is so critical.  If they can in a collegial manner demonstrate the beauty of the practice of Thoracic surgery, we will have no trouble attracting the best and the brightest students to our discipline.  I would urge you and others who have a budding interest in this specialty to find a mentor to meet your needs.  They are there, only some may need a little more pushing than others.

Thanks again for your letter and your insights into our specialty. 

Keep the faith.

Sincerely,
Ben

Benson R. Wilcox, M.D.
Division of Cardiothoracic Surgery 
The University of North Carolina
Chapel Hill,  NC   27599-7065 
United States

Dear Sir,

I apologize for not having written to you earlier and kept in touch. I was unable to secure an elective in a cardiac surgical unit in the United States as I was unable to take my USMLE Step 1 exam in time for it. I have just started my 5th (and final) year in medical school. I spent a total of 8 weeks in India doing my overseas electives in various disciplines of surgery. 2 weeks each in neurosurgery, general and renal transplant, plastic surgery and adult and pediatric cardiac surgery. I had an awesome time, particularly in the cardiac surgery elective. I was at a hospital, named Narayana Hrudayalaya in the city of Bangalore, India. This hospital is huge. This hospital has a 60+ bed ICU for pediatric cardiac surgery and  another 60+ bed ICU for adult cardiac surgery. There are at least 10-12 pediatric cardiac surgeries and another 10-12 adult cardiac cases listed each day. So the clinical volume is huge. And since this is my 3rd visit to the hospital, my involvement was even greater. I was grantend the oppurtunity to be scrubbed up for a  variety of procedures such as valve replacements, aortic anerysm repairs, and some other pediatric cases. As a medical student, this is a fascinating experience.

So now I am back in Singapore, in my final year preparing for my final exams which would be in March 2007. After which, I am required to do a 1 year internship here. By end 2007, I should be ECFMG certified so that I may consider pursuing a residency training position in the United States. I thank you for your help thus far in inspiring me and motivating me and I am truly glad that the article has been accepted for CTSNet.

Regards,
Ashok V.

Publication Date: 25-May-2007
Last Modified: 18-Jul-2008