Who Moved My Residency Program?

"Who Moved My Cheese? is a simple parable that reveals profound truths about change."(1) It describes four characters, two mice named Sniff and Scurry and two 'little people' Hem and Haw, who are the same size as mice but act and appear like people. Sniff and Scurry possess simple rodent brains, but have good instincts. They would try and smell out the general direction of cheese and Scurry would race ahead. They would often get lost but after awhile would find their way. Hem and Haw used their ability to think and learn from their past experiences, although their brains were also filled with many beliefs and emotions that occasionally took over and clouded the way in which they looked at things. They live in a maze and look for 'cheese' for food and happiness. "Cheese is a metaphor for what you want to have in life-whether it is a good job, money, health, possessions, or peace of mind" (1) - - or in this essay, the cheese is an improved residency program. "The maze is where you look for what you want - the organization your work in, or family or community you live in." (1) - - or in his essay the various organizations that represent the specialty of Thoracic Surgery. To be more specific, the organization could refer to the Joint Council of Thoracic Surgery Education. "In this story, the characters are faced with unexpected change. Eventually, one of them deals with it successfully and writes what he has learned from his experience on the maze walls." - - or in this case the characters are the thoracic surgeons and thoracic surgery program directors who have contemplated, analyzed, discussed and in some cases argued about the necessity for a change in the residency program. (In this manuscript, the text in italics refers specifically to the book "Who Moved My Cheese?)"

"Sniff and Scurry daily inspected the area in the maze where the cheese was and realized that the supply was getting smaller each day. They were prepared for the inevitable and went about looking for new cheese. Hem and Haw were unprepared, as they had taken for granted that the cheese would always be there." Several of us were aware of the decrease in both number and quality of resident applicants, but it was the foresight of Dr. Fred Crawford who recognized that this could eventually evolve into a significant problem for our residency programs and our specialty. He commissioned an Ad Hoc Long Range Planning Committee within the American Board of Thoracic Surgery (ABTS) to discuss the issue of the requirement for American Board of Surgery (ABS) certification as a prerequisite for ABTS qualification and certification. If this one significant requirement could not be altered, no new or innovative changes could be made in the residency program. After considerable discussion and debate, recommendations were brought forward at a retreat to the entire ABTS Board for further thought, deliberation and action.

As one of the characters in the book said, "Maybe we should stop analyzing the situation so much and just get going and find some New Cheese." These book characters also pointed out the difference between activity and productivity. At the Board Meeting of October 1999, the following resolution was passed. "The Ad Hoc Long Range Planning Committee recommends that the ABTS change it's current policy regarding ABS certification so that at a point in the future, yet to be determined, ABS certification will become optional. The ABTS will meet with other organizations involved with thoracic surgery education (Residency Review Committee, Thoracic Surgery Directors Association, American Association for Thoracic Surgery, Society of Thoracic Surgeons, American College of Surgeons) to discuss the significant implications of this decision."

The Joint Council for Thoracic Surgery Education (JCTSE), which had been established to entertain issues dealing with education common to all of thoracic surgery organizations, was asked to be the focal committee to address this ABTS Board resolution.

Dr. Crawford had previously been elected Chairman of this Council. The Council is made up of two representatives from each of the parent organizations. These included the following organizations and their representatives. (Table 1)

This Council met twice a year over the ensuing two years. It was the focal point for input, discussion and feedback to and from the parent organizations.

There was considerable concern and opposition to this new concept. In the book one of the characters "Hem" was not interested in change. He was worried about getting lost in the maze while he was looking for New Cheese. He wanted to stay in familiar territory. The other mouse Haw knew some fear should be respected, as it can keep you out of real danger. But he also realized sometimes his fears might keep him from changing when he needed to.

All of us in thoracic surgery had similar concerns about potentially changing a program that had produced outstanding thoracic surgeons over the last several decades. These fears were for legitimate reasons in that the change can occasionally be harmful rather than helpful.

The mice in this story do not over-analyze or complicate things. They comment that there is always New Cheese out there whether you recognize it at the time or not, and you are rewarded with it when you go past your fear and enjoy the adventure.

Everyone in thoracic surgery education recognized that this potential change would be the most significant event since the establishment of a unique thoracic surgery residency program a number of years ago.

Deliberations by the Joint Council were influenced by periodic input from the parent organizations. The manpower study, as commissioned by The Society of Thoracic Surgeons, indicates that many individuals are retiring early, and that there will be a constant need for more thoracic surgeons in the future. The Thoracic Surgery Directors Association convened a separate meeting in Chicago to discuss in detail the proposed resolution from the ABTS, its implications and the formulation of what a potentially new residency program might consist of with regard to curriculum, requirements and years of training. The Thoracic Surgery Residents Association provided data from a survey conducted with the current residents. This survey revealed that approximately 2/3 of the current residents had decided upon a career in thoracic surgery while in medical school, with the remainder of residents indicating their desire to become a thoracic surgeon within the first two years of general surgery training. The TSDA meeting reached consensus on several concepts. The majority of participants felt that if it were possible to design a new residency program, it would be different from the current one. Most felt that the current residency program could be significantly improved.(2)

After nearly two years of meetings and discussion among all of the parent organizations, the Joint Council issued its final recommendations at the July meeting of 2001. These recommendations were subsequently endorsed in principle by the Residency Review Committee at its meeting in July of 2001. The American Board of Thoracic Surgery at its fall meeting (October 2001) also ratified these 10 recommendations from the JCTSE with minor modifications. These included:

1. ABS certification will no longer be mandatory for ABTS certification but instead will be optional.

2. One pathway to ABTS certification will continue to be "traditional" - full general surgery residency (5 years plus or minus ABS certification plus 2-3 years in thoracic surgery).

3. A second pathway to ABTS certification will be an integrated six year thoracic surgery residency along the guidelines developed by the TSDA. All currently approved thoracic surgery residencies will be offered the opportunity to apply for the development of such programs. The standards and requirements of such programs will be approved by the Thoracic Surgery RRC. Such integrated programs will only be developed in institutions with an ACGME approved general surgery residency, and individuals would match out of medical school or at a subsequent time.

4. A third pathway to ABTS certification would include 3 years of thoracic surgery residency after a minimum of three years in an ACGME approved general surgery residency so long as certain prerequisite requirements have been met. These requirements are:

5. The JCTSE strongly encourages the American Board of Surgery (ABS)and the Association of Program Directors in Surgery (APDS) to develop a shorter curriculum in "surgery" - to include ABS certification - which if and when approved would permit an alternate pathway to ABTS certification.

6. The JCTSE strongly encourages the ABS and APDS to participate in the development of a surgical preparatory core curriculum as a standard for entry to ACGME boarded surgical specialties.

7. Any individual currently in the ABTS certification process (i.e. in a thoracic surgery residency or already finished a thoracic surgery residency) will be guided by requirements in force at the time of his/her residency.

8. The JCTSE strongly encourages the Thoracic Surgery RRC, as a part of the special requirements for thoracic surgery residencies, to require documentation of faculty participation in medical school curriculum.

ABS certification will no longer be mandatory for ABTS certification but instead will be optional. This recommendation allows for the creation of a variety of pathways to ABTS certification. These include the traditional full general surgery residency (5 years ± ABS certification + 2-3 years of thoracic surgery training). The second pathway is an integrated six year thoracic surgery residency program. These individuals would have generally matched out of medical school. A third pathway to ABTS certification is a 3/3 year program with prerequisite requirements having been met in the first 3 years of general surgery. The other JCTSE recommendations that were endorsed by the ABTS include language to encourage the American Board of Surgery and the Association of Program Directors in Surgery to develop a preparatory core curriculum which may act as a basic starting point for entry into a variety of surgical ACGME board surgical specialties.

This momentous decision on the part of the American Board of Thoracic Surgery will result in significant changes within thoracic surgery education. The underpinning to these changes is to provide the utmost flexibility for residency program directors and their residencies (within guidelines and standards developed by the RRC with input from the TSDA).

This change in the thoracic surgery residency program as outlined by the ABTS has to be formally presented to the American Board of Medical Specialties(ABMS) for their approval. This is a detailed process that can take 1-2 years for the eventual adoption of a new residency program.

All of us in thoracic surgery can equate with one of the book characters (Hem, Haw, Sniff and Scurry). Hem remained adamant against change. He was afraid to leave his comfortable surroundings and take a risk. Even when Haw offered him New Cheese that he had found, Hem did not take the New Cheese, as it was not what he was used to. Haw eventually overcame his fears and concerns and actually started to enjoy the search for New Cheese.

All of us in thoracic surgery have concerns about the change in the residency program, but many of us feel that overcoming this concern is important for the future of this specialty. We realize that this is in part an experiment, especially in the integrated pathway where residents will be selected out of medical school.

However, there is a precedent for this type of integrated program - Duke University and recently Johns Hopkins University conducted successful integrated thoracic surgery residency programs but within the limitation of surgery certification. Changes in the program will have to be continuously evaluated to improve the "New Cheese."

Haw realized that he could slip back to complacency if he got too comfortable. Each day he inspected the New Cheese station to check out the condition of his cheese; he was going to do anything to avoid being surprised by unexpected change. He was more comfortable now to explore new areas and be aware of his real choices than to isolate himself in his comfort zone.

Like the story, we will have to continue to embrace the change and look for new ways to develop and enrich the curriculum. While doing this, it is important to maintain an educational dialogue with all members of our specialty to ensure their understanding of these changes and the importance of embracing the change and participating in this new and continuing educational process. It is our hope this will help in part to re-invigorate our specialty and attract "the best and brightest" into our wonderful profession.

References

1. Who Moved My Cheese? Johnson S (ed), G.P. Putnam's Sons, New York, New York, 1998
2. Olinger GN. "Change in the Wind": Report from the 2000 Thoracic Surgery Directors Association Retreat on Thoracic Surgery Graduate Medical Education. Ann Thorac Surg 2001;72:1433-1437.