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Eur J Cardiothorac Surg 1999;16:S6-S10
© 1999 Elsevier Science NL
Division of Cardiothoracic Surgery, University of California, Davis Medical Center, Sacramento, CA 95817, USA
Key Words: Education • Surgery
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1. Before thoracic surgery |
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 Top 1. Before thoracic surgery 2. Thoracic surgery3. Reality4. CommentaryReferences |
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The ‘art of surgery‘ was recognized at the time of Hippocrates [1,2]. In the beginning surgery was totally integrated into medicine as a whole and it was taught by apprenticeship, without curricula or standardization or formal evaluation. Hundreds of years passed until surgical papers were segregated into separate sections in scientific publications. Meetings devoted exclusively to surgery did not emerge until about the 1890s.
Europe was the cradle of knowledge and excellence in surgical education for Americans in the late 1800s until approximately the start of World War II. It has been estimated that during the period from 1870 to 1914 there were 15 000 US undergraduate and postgraduate students in German medical schools alone. There were also many Americans studying in centers of excellence such as Vienna where the great Chicago surgeon Arthur D. Bevan noted that Billroth ‘...taught surgery as a successful football coach teaches his squad...by training them in the actual work itself'[2].
In the youngest days of America as a British colony, medical education was fragmented and sporadic. The first American surgical textbook was a manual of military surgery in 1775.
After the Declaration of Independence in 1776 there was little attention paid to medical education until formal medical education began at the Medical College of Philadelphia in 1865. At the start surgery was taught under the aegis of a professorship that also included responsibility for anatomy and midwifery as well as surgery. Eventually, Philip Syng Physick became the first professor of surgery as a separate and distinct discipline.
New York, Boston and Baltimore were the centers of surgical excellence in the original 13 states; Chicago and Rochester, Minnesota led the way in the Midwest. At Bellevue Hospital, now the major clinical teaching center of New York University, Stephen Smith in 1863 noted that the theoretical schools of the ancients ‘...do not teach practical medicine. They educate the brain, but leave the hand palsied.... Their graduates (are) like full fledged eaglets deprived of their wings' [2].
At the Massachusetts General Hospital, Henry Bigelow said ‘Clinical study is bed study. Here the student grapples with the malady whose Protean forms he has as yet only read...' [2]. In short, the late 1800s in the United States saw a recognition of the need for practical experience in surgery. In the language of sports, surgery was recognized as a body contact sport.
At the Johns Hopkins Hospital, Harvey Cushing, best remembered for his fundamental contributions to neurological surgery and whose greatest pride was in having sewn dura, conducted a course in animal surgery. He managed to carry this forward in large part because he defused the objections of anti-vivisectionists for whom he also served as a veterinary surgeon. Cushing said the animal surgery course ‘was by far the most satisfying and profitable source of contact between student and teacher I have ever experienced.... I believe it will make the future physician more appreciate of the surgical viewpoint' [2].The professor of surgery at John Hopkins University was William Stuart Halstedt, a fascinating man who is often credited with having started the first true residency in surgery. Under Halstedt, the residency included no lectures or known curriculum. There were formal systematic sessions in Surgical Pathology.
From the Mayo experience one learns more about the evolution of surgical teaching in the 1800's. Will W. Mayo in 1849 at the Indiana Medical College learned from lectures without clinical instruction. The young Will Mayo, in 1879 at the University of Michigan did have clinical instruction in surgery, but it was long distance education in amphitheater. By the time Charles Mayo attended the Rush Medical College in Chicago in 1885, he was able to observe actual operations at close range.
Then came the Flexner Report of 1910 which called attention to the appalling level of medical education in the U.S and Canada [3].Flexner said that ‘ (The) pedagogical value (of surgery) is... slight;... operations are performed in large amphitheaters.... Most students see only the patients' feet and the surgeon's head'. It was clear that surgical education, like the rest of medical education, needed a new and different approach.
In Chicago, my medical home town, the importance of the surgical laboratory was championed by the great Christian Fenger who advised his students to ‘Beat a path from the operating room to the laboratory'. Writing about Fenger, Hertzler said that his experience in surgical pathology had been one of the most valuable lessons he had learned [4].
I had the privilege of being the last chief resident at the University of Chicago in the Dallas B. Phemister tradition. Phemister allied surgery with basic science. Among his most successful surgical faculty members was Lester R. Dragstedt who had been recruited by Phemister from his position as a physiology faculty member and sent to Europe to learn surgery. I am not sure if it was Phemister or Dragstedt who said that the laboratory must be ‘hatless distance' away from the Operating Rooms. In any case, that is the way it was. Dragstedt, the physiologist and originator of vagotomy as treatment for duodenal ulcer, conducted daily afternoon teas in his laboratory. This wonderfully civilized way of connecting the operating room with the research laboratory persisted ever after ‘LRD' succeeded Phemister as the professor. The surgical amphitheater was replaced by 1:1 resident/faculty preceptorships of 6–12 month durations. Everyone served as a surgical pathology apprentice for at least 6 months. A single resident each year was selected to become chief resident and Instructor. When I had this privilege I was already certified by the American Board of Surgery. All but one of the Phemister tradition chief residents became full professors If I were pressed to select one of the University of Chicago surgical products of the Phemister era as the most prominent, I would choose Charles E. Huggins who was awarded the Nobel prize for his work with the endocrine control of breast and prostate cancer.
The evolution of surgical education until now is illustrated by looking back at surgical education during the time of three surgical Nobel Laureates. In the days of Theodore Kocher, awarded the Nobel Prize for his work with the thyroid, there was absolute professional authority. Young surgeons were anointed when they were judged to be ready for independent work by their elders who were benign dictators;. In the Huggins era of about 1945 to about 1970, the seeds of postgraduate curricula in surgery emerged. By the time Joseph Murray received the Nobel Prize for his work in transplantation, there was an Accreditation Council for Graduate Medical Education in the US and each specialty had a well defined structure for its residency programs. The system is not perfect, but it has become increasingly defined. It is certainly better now than ever before insofar as the average surgeon in residency is concerned. I am not sure that the system offers the upper 10% of surgical residents the same opportunities as heretofore.
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2. Thoracic surgery |
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Top1. Before thoracic surgery2. Thoracic surgery3. Reality4. CommentaryReferences |
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The earliest elective thoracic surgery was practiced predominantly in the tuberculosis hospitals. Often the need for a service that did not exist initially pushed internists and generalists into surgical adventures. By 1917 the men who wished to focus upon thoracic surgery had come together in the American Association for Thoracic Surgery. Eleven years later, John Alexander, himself a victim of tuberculosis. had started the first residency in thoracic surgery at the University of Michigan. Two decades later, in 1948, the Board of Thoracic Surgery was formed as an affiliate of the American Board of Surgery. Twenty three years thereafter, in 1971, the American Board of Thoracic Surgery became independent of its general surgery parent board, although to this day each of the two boards has a liaison member from the other. In 1978, led by Hassan Najafi, the directors of approved residencies in thoracic surgery came together as the Thoracic Surgery Directors Association. As cardiac surgery matured, there was much pressure to change the name of the American Board of Thoracic Surgery to reflect the importance of cardiac surgery [6]. A series of important, thought provoking, meetings to discuss education has taken place in the past 20 years. These included a strategic planning meeting of the Society of Thoracic Surgeons (STS) – the largest group of thoracic surgeons in the world [7]. The STS reaffirmed the definition of thoracic surgery as a unified specialty that now includes three sub-specialties of cardiovascular: surgery for adults, general thoracic surgery and congenial heart surgery. The Thoracic Surgery Directors Association, after a retreat the involved intense discussions the leaders of all approved residencies, confirmed that thoracic surgery would remain a unified specialty with three recognized sub-specialties. There was strong consensus that Thoracic Surgery Program Directors should become increasingly responsible for the pre-requisite surgical education and significant opinion in favor of dropping certification in general surgery as a prerequisite in order to allow better and longer focus upon thoracic surgery. However, there was consensus that the pre-requisite of certification in general surgery has served thoracic surgery well and that it should be kept [8].
There is unanimity that excellence in clinical education is fundamental. Neither political or financial considerations must deter us from that conviction. An important component of this excellence is the Residency Review Committee (RRC) in thoracic surgery that sets down criteria for residencies in the form of special requirements. The RRC evaluates educational programs through a detailed review process that includes site visits and interviews of the residents. Its deliberation result in approval or disapproval of educational programs in thoracic surgery. In short, the RRC has authority over programmatic matters; it has no authority or responsibility for certification of the graduates of these programs. The American Board of Thoracic Surgery (ABTS) evaluates each graduate of an approved thoracic surgery program. In order to be eligible for ABTS examination an individual must be previously certified by the American Board of Surgery (general surgery), and he or she must have completed 2 or 3 years dedicated exclusively to thoracic surgery in an approved residency. The graduate must show that he or she did a minimum of 125 major operations per year, including a minimum number of cases in each of the subspecialties of thoracic surgery. Despite these rigorous requirements, about 12–20% of the candidates have been unsuccessful in the written examinations which are designed to test the knowledge base. Thereafter, about 10–15% have failed during their oral examinations which are designed to test judgement and safety. In recent years, ABTS has moved to a so called ‘criterion referenced' examination under which there is no obligatory failure rate. There is the hope that the residencies in thoracic surgery will become uniformly so good as to allow every candidate to pass the ABTS examination.
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3. Reality |
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Top1. Before thoracic surgery2. Thoracic surgery3. Reality4. CommentaryReferences |
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This year, from South Carolina – a rural state, the results of a survey of 1583 pulmonary resections were reported under the title ‘Specialists achieve better outcomes than generalists for lung cancer surgery' [11]. Only 47% of these operations were done by fully educated and certified thoracic surgeons. The general surgeons did significantly more pneumonectomies than the thoracic surgeons, thus indicating that the general surgeons chose the easier operation when a lesser but more difficult resection such as lobectomy or segmental resection might have been better for the patient. The morality rate among patients who had lobectomies by general surgeons was significantly higher as compared to the rate among patients whose operations were done by thoracic surgeons. When the outcomes were analyzed according to the patients' preoperative co-morbidities it was noted that the death rate among very sick patients operated by generalists was significantly higher than the death rate among patients whose operations were done by thoracic surgeon. Of additional concern to me was the finding that 75% of the generalists did less than 10 lung resections for cancer annually and that they were younger than the thoracic surgeons. This information suggests that patients and referring doctors are accepting thoracic surgery as a part of the armamentarium of general surgeons who are incompletely educated in thoracic surgery. Most such surgeons do thoracic surgery so infrequently that it is safe to conclude that they cannot be thinking about thoracic problems regularly. One can summarize by saying that more than half of the operations for lung cancer in South Carolina are being done by general surgeons who have chosen to undertake pneumonectomies when lesser, but more challenging operations might have sufficed. High risk patients and patients who had lobectomies by general surgeons did more often postoperatively as compared to patients whose operations were by certified thoracic surgeons.
There are corroborating data from Europe. In the Netherlands, the outcome of 344 patients who had thoracic surgery in 3 centers from 1991–1995 was studied [12]. Two of these centers had general surgeons doing the operations and the third had fully educated thoracic surgeons practicing their specialty. The incidence of pneumonectomies in the two centers with general surgeons was 34 and 37% as compared to 24% in the thoracic surgical center. Postoperative morbidity was higher in the general surgical centers; mortality rates were 10 and 9% in the general surgical centers and 4% in the thoracic surgical center.
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4. Commentary |
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Top1. Before thoracic surgery2. Thoracic surgery3. Reality4. CommentaryReferences |
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My first proposal is intended to assure that thoracic surgery keep control of general thoracic surgery and set standards in that sub-specialty. I suggest that we do this by meeting the needs of the patients who wish to be cared for as close to home as possible, and the desires of postgraduate surgical students (residents) who wish to specialize in general thoracic surgery. A fundamental step in keeping control of thoracic surgery is to measure outcomes. The quality of these measurements must be beyond reproach so as to avoid being seen as self serving. I further suggest that there may be some general surgeons, who come from ‘mixed programs' such as the one in which I was educated who are currently practicing acceptable thoracic surgery. I accept the reality that it is impossible, and perhaps even undesirable, to stop that practice until an acceptable substitute is in place. These general surgeons currently have no access to groups like the STS and the General Thoracic Surgical Club, and so they are denied important opportunities to keep up with progress. If I were king, I would take the difficult step of taking in these general surgeons after we develop mechanisms for evaluating their work. The ‘good guys and girls' among the general surgeons would be ‘grand fathered', and no new general surgical graduate would be granted privileges in thoracic surgery. If a thoracic surgeon who enters practice in a medium size or small community needs to do some general surgery, I would not object; thoracic surgeons are after all certified, fully educated general surgeons before they undertake additional education. The fact that a thoracic surgeon does general surgery should not be grounds to exclude him or her from our thoracic surgery organizations.
My second recommendation is that we undertake a program to teach the public and physicians in other fields the value of thoracic surgery. While achieving this goal, we must insist on excellence in thoracic surgical education and practice. This can currently best be done by keeping general surgery certification as a prerequisite for thoracic surgery education. We must recognize the currently unmet community needs for general thoracic surgery and meet that need by developing a general thoracic track of thoracic surgical education. I purposely do not propose a certain amount of education time for cardiac surgery, general thoracic surgery or congenital heart surgery. Instead of time, the emphasis in education needs to be on content and learning. The time framework must be secondary to careful consideration of content.
In closing, I wish to look to the future. Before doing so, let me mention some of the existing obstacles to surgical education and the opportunities that will help us to overcome these blocks. The first obstacle is the arrogance of cognitive physicians who paint surgery as a technical trade that is beneath them. These are the forces, that claim surgical services have been overvalued. A second obstacle is the current emphasis on production line efficiency in health care. Such a mentality does not make allowance for education. The concept that undergraduate or postgraduate surgical students can learn by watching was proven wrong over a century ago. Thirdly, our educational goals are blocked by the paucity and progressive shrinkage in funds allocated to medical education.
The opportunities in surgical education remain enormous. The young people of today are better prepared than we were, in part because computer technology can be a terrific aid to education. Moreover, the public is now much better informed than in previous times. Thus, we can enlist the support the public in our insistence on the maintenance of high quality in surgical education.
Our host, Professor Anthony Yim laid the groundwork for the future of surgical education in one of his recent publications when he said, ‘The world of medicine is rapidly changing, and the pattern of cardiac surgery at the turn of the millennium will probably be very different from that we were trained for' [13]. Since we cannot predict what thoracic surgery will be like in the future, education – not training – is the key to continuing success. Training is a way to teach followers and repetitive skills. We arrived where we are because thoracic surgeons are broadly educated physicians who have devoted additional time to surgery. It is the breadth of our education that has allowed us to develop ever better ways to treat our patients and to adapt to changing needs. We have come far but the future is further yet. Excellence in surgical education will insure that what is to come will be even better than the past.
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Footnotes |
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Presented at the 2nd MITSIG International Symposium: Controversies in Cardiothoracic Surgery, Hong Kong, November 20–21, 1998.
1 Contact address: 11611 Terryhill Place, Los Angeles, CA 90049, USA. Tel.: +1-310-889-9186; fax: +1-310-889-9196 
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References |
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Top1. Before thoracic surgery2. Thoracic surgery3. Reality4. CommentaryReferences |
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