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Eur J Cardiothorac Surg 2004;25:1-5
© 2004 Elsevier Science NL
EACTS Presidential address |
Department of Cardiothoracic Surgery, University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria
Received 6 November 2003; received in revised form 24 November 2003; accepted 24 November 2003.
* Tel.: +43-1-40400-5644; fax: +43-1-40400-5642
e-mail: walter.klepetko{at}akh-wien.ac.at
Ladies and gentleman, members of EACTS and ESTS, friends and guests. It is an outstanding moment in a personal career to be introduced to a distinguished audience such as this one and it is an even greater experience and honour to serve an organisation like this one in the role of a president. I can only say how humble and grateful I feel for that. Nothing like that can be achieved without strong support and among the numerous people who have helped me in my career and in my work, I would like to point out a few. My parents set the prerequisite for everything by giving me the strong base of a loving and protected childhood. My wife and my children have been the strongest motivation and support that one can imagine. All of them are here, and it is difficult to find adequate words to thank them.
In my professional career I have received furtherance from many people, two of them I would especially like to point out. Ernst Wolner, who offered me the ideal mixture of guiding support and freedom of action at the same time, that was so important during my formative surgical years. Toni Lerut, who promoted me in the general thoracic community from very early on. I want to sincerely thank both of them. I also want to express my gratitude to the colleagues and co-workers in my department who have gone a long way together with me and who have helped and supported me especially during the last year full of different commitments. My special thanks and my appreciation go to the members of the Vienna lung transplantation team, who have done such a great job by keeping numbers and quality up, despite my reduced presence.
I have chosen the title, visions and revisions, for my lecture. In fact, the strength of any rising organisation relies to a great extent on the visionary capacity of those who were the promotors of the first hour. After some time, when these visions have initiated a process, it becomes important to put the result into perspective within the more recent conditions and demands of a meanwhile changed outer world. Performing such an analysis, becoming aware of the changed circumstances and subsequently revising and adapting what has been achieved, when would that be more appropriate than at the time when a society comes back to the place from where it started.
In 1987, this association convened for the first time here in Vienna, at that time in the splendid and famous environment of the ‘Hofburg’, in the centre of the city. It was the first meeting of a newly founded society, driven by the two components, vision and enthusiasm, on its way to find its place among a number of other already existing and established scientific organisations.
At that time it was intended to represent both, cardiac as well as thoracic surgeons. The economic background for surgery in general was extremely prosperous and became even better throughout the following decade. The idea of a unified Europe was emerging and was realised only 5 years later by the Treaty of Maastricht.
Residents in CT surgery considered their position a privileged one and therefore worked with an extremely high level of motivation. Length of working time was not an issue of discussion in general, but much more important was the desire to gain access to high level quality education.
Under these circumstances our association was created, the bylaws were formulated and Francis Fontan in the first presidential lecture, described the visions that were behind them [1].
Vision 1. "...To create a European Forum for presentation of CT science..."
Having experienced for years that the best scientific European work was presented at meetings outside Europe, with limited chances to be brought to the knowledge of a larger and especially younger European audience, the idea was to create a European Forum, that encompassed both the live presentations and discussions at annual meetings, as well as the publication of material within a regularly appearing journal. The following success story is well known to all of us. Today we welcome more than 3000 participants to our meetings, we run a journal that has continuously increased its impact factor, and we recently started a parallel endeavour, with the creation of the ‘Interactive Journal’. It is fascinating and can fill us with pride to observe to what extent this vision has become reality.
So which aspects should we consider to be important for the future in that regard, and where can we identify elements for further improvement?
Vision 2. "... To advance education in cardio-thoracic surgery..."
The second goal of this association focused on the promotion of education, and it was central to the vision to establish educational conditions throughout Europe that should allow to have ever better trained future generations of CTS. Undoubtedly, we have achieved impressive progress in this area as well. No one would have ever expected such quality and quantity of educational tools as we can offer today. We are providing outstanding opportunities for postgraduate education at our annual meetings, we are offering educational grants and we have introduced several other important features, among them the founding of the European Postgraduate School in Bergamo. Theoretically, conditions for education in CTS are the best that we have ever seen. But does this make our specialities more attractive to young people and will it result in the best-trained CTS that we all want to achieve? 17 years earlier, we might have answered with a clear yes, but unfortunately the reality that we are facing today is a different one and not only our American colleagues observe that resident positions remain unfilled, or attract only those with a mediocre curriculum.
The image of our profession as it is seen, especially by the younger generation, has changed significantly and there are several reasons for this. The phenomenon can be explained only in part by pronounced changes in life style attitudes which have occurred in general and which focus on a much higher appreciation of individual and private life. The more important part is however related to factors that are well within our own responsibility.
Extensively long training times not focused sufficiently on the core issues of CTS, combined with the uncertainty of obtaining adequate positions thereafter, are among them. The lack of structured training in several countries and especially an increasing lack of personal mentorship is another one. And in general, residents in medicine and particularly those in CTS, who are in their late twenties, usually find themselves in a much more dependent professional situation, compared to their friends in other professions who are of the same age.
To counteract these trends will be a challenge for all of us at the individual level as well as at the level of our society. We will need to improve the image of our profession significantly, by giving evidence to the outside world and to our residents, that the laborious and difficult working conditions that we face, do not necessarily imply a reduction of quality of life, but rather can offer unique experiences and a draught in human existence that hardly can be obtained in any other profession. CTS remains a profession that can offer fascinating opportunities and challenges to those working in it.
In addition to such an image campaign that must derive from our daily performance, we will have to improve our working conditions in general, in order to make them more attractive to young colleagues. I have no doubts about the fascination itself that our profession can offer, and I have no doubts about the enormous theoretical material that we are offering to support education, but I am concerned about the conditions under which European residents sometimes work. Personal mentorship should be seen as a challenge to all of us and needs to be reintroduced as an important aspect of education. Offering residents a clearly structured curriculum, instead of using their endurance simply to compensate for deficits in our organisational systems should become self-evident. Respecting individuality and personality will be equally important.
By keeping in mind that the motivation of our residents will always be depending on their possibility to perform adequately to their individual grade of training, we can help to make training in CTS an exciting adventure. For academic science the importance of this relation of ability to responsibility was pointed out by Marc de Leval in a lecture several years ago and the same relation can as well be seen as the main driving factor for clinical performance. Only those who get the possibility to perform at the level of their abilities will enjoy the necessary level of motivation.
So what can be done by our association and our specialities in general, to further be instrumental in this process?
Vision 3. "...To become a European platform for CTS and to give advice to legal authorities..."
Many of the problems I have mentioned so far already underline the importance of the third aim of this association: to become a European platform for CTS and deriving from there to give advice to legal authorities.
During talks with colleagues from many different countries, I have realised that a significant number of them still underestimate the necessity of such a European representation. In fact, when we experience on a daily basis, that more and more regulations are now introduced on a European level, clearly impacting on our local working conditions, it becomes obvious that this is an even more important issue than it was at the time of the founding of this society. CTS is not a large opinion group and it could likely be that our voices are not sufficiently heard and that not enough attention is paid to our interests, unless we are able to concentrate our forces and to advocate our opinions and interests. Although the geographical area which we are representing, goes well beyond the political border of the European Union, in reality we are increasingly dependent on EU regulations and it is therefore even more important that we are able to argue and to act at this level.
In the future it will be even more important that our association takes an active role in political aspects. Our American partner organisation, the STS, recently has restructured their organisation and among the three new councils that have been introduced, one is dedicated to health policy affairs and relationships. This demonstrates how much attention they pay to these aspects. The American situation certainly is not comparable to the more heterogeneous European one, but the important principles are the same. We need to become an even stronger political voice than what we already are in order to defend the interests of CTS within Europe.
I would like to give one example of importance: the implementation of the European working time directive.
This regulation certainly has an enormous impact on many different working areas, however its particular impact on medical and especially surgical areas has to be characterised as being clearly deleterious. Especially in surgery, where improvements in individual performance quality can only be achieved through growing experience, it will be difficult to accumulate sufficient know-how without investing additional time. For surgeons, and especially for CTS, experience means active participation in a large number of procedures since we have to deal with sometimes rare problems and we have to reach a unique grade of technical perfection and professionalism. What would be the impact on the performance of top sportsmen and artists if their training time were to be significantly restricted? Would it not become mediocre very soon? For our profession we have to foresee at least three clear effects of the upcoming restriction in working time. First, it might well create a new need to extend our training times again. Secondly, it might be instrumental to the complete separation of our specialties, cardiac and thoracic surgery, since it is already now impossible for a resident to acquire the extensive theoretical and practical knowledge of both fields during his official training time. And finally, organisational needs deriving from this law will ultimately favour departments of larger volumes, which will be the only ones who can economically provide the necessary staff requirements.
The worst scenario that could be foreseen, and I would like to call this the ‘Deadly trias for CTS education’, would be a resident, who is working in a low volume department under the rules of the European working time directive and at the same time is confronted with a severe restriction in the number of interesting positions in his future. This in my understanding can only result in severe limitations for the future performance of cardiothoracic surgeons.
Another important issue that has to be mentioned here is the estimation of the future needs for CTS positions in Europe. Although it is extremely difficult to foresee this need, a long time ahead, it will however be of outmost importance to come up with some realistic estimates and consequently try to adapt the number of training positions accordingly. I would see it as an important task for our association, to take an active role in that regard and to advise authorities in this important matter. Only in this way, will we be able to avoid frustrating experiences for those passing a long curriculum and discovering at the end that the market for CT positions is already filled. All this demonstrates how important it will be for us to maintain our ability to raise strong voices on the European level.
We will have to commit ourselves to play an active role in finding solutions to these problems and more importantly, we will have to address problems in a prospective way, by coming up with solution models before they are imposed on us by authorities who do not necessarily have detailed insight and understanding of our situation.
In order to reach this we also will have to intensify our contacts and cooperation with the national organisations. EACTS will have to link in a more intensive way with the national societies; it will have to act as an integrative force, in order to identify matters of common interest and to be instrumental in their realisation. For the first time a meeting between the leadership of EACTS and the chairmen of the national societies has taken place at this conference and this can be seen as a starting point towards a new cooperation from which new opportunities in the realisation of important cardiothoracic goals and interests should derive.
Vision 4. "... To represent both, cardiac and thoracic surgery..."
The last issue that I want to discuss, refers to the relationship of cardiac and thoracic surgery, a topic that was central in my interests throughout my presidency year.
In the beginning, this association has intended to become the home for both, cardiac and thoracic surgery. Unfortunately, this vision of a common representation disappeared, when a second organisation was created with the foundation of ESTS, which meanwhile has become a powerful society as well.
The resulting split in representation has been enormously detrimental for GTS, which already is suffering from the large variety of different settings in which it is performed, as well as from the limited incentive in many combined departments, to develop and promote the speciality itself. It has however been detrimental for cardiac surgery as well, which lost the contact with the majority of practising thoracic surgeons.
This double representation, this dispersion of capacities and this unsatisfactory state of affairs in general, has been perceived by the leadership of both societies during recent years. EACTS has realised the importance of keeping GTS close to cardiac surgery, while at the same time ESTS has become aware of the advantages of a strong common representation.
A philosophy of preserving the identity and speciality of GTS and at the same time offering a common platform within a larger cardio-thoracic framework was therefore developed and proposed. This resulted in a number of achievements and joint projects well known to all of you and only through this ideology has it become possible to hold for the second time a joint meeting of the two major bodies of GTS in Europe.
However, all this will not be sufficient to guarantee that the future course of cardiac and general thoracic surgery will go in parallel and that the vision of the general representation of GTS in our association can be maintained. It will take major changes in our understanding of the position of the two specialities and we will also need to create permanent circumstances which are satisfying to both groups.
It may seem strange that all this needs to be emphasised repeatedly, however surprisingly the ‘win–win’ scenario that is inherent in such a partnership does not become immediately obvious to everyone.
The most important goal to achieve on the way will be the acceptance of general thoracic surgery as its speciality. This already has been done at the level of the UEMS, it is gradually becoming accepted in our association and it definitely needs to be reinforced in the daily practice of clinical performance. The whole spectrum of cardiac and general thoracic surgery can no longer be performed at the same time by one single surgeon to the necessary high quality requirements that are mandatory today, and the same holds true for the combination of general surgery and thoracic surgery. This fact therefore needs to be translated into the structural design of the individual departments.
It has to be understood and accepted that it will be a vital question for GTS to develop its own field and to reassemble its activities and efforts which are currently dispersed over different specialities. On the other hand, this does not imply that GTS and cardiac surgery should not stay close together. Given the enormous synergistic effects that can be identified in the close relation and the working together of both specialities, it would be extremely unwise not to take advantage out of them.
Another significant problem for GTS represents the clear restriction in the number of independent academic positions in some countries. It is fairly clear that, only through a significant increase of these positions, can a profound development of the specialty occur. Analysing the current scientific output in GTS clearly shows that a large number of contributions are still retrospective case series only and that we have to work intensively on the quality of our scientific output. That such a concept can create a new category of scientifically outstanding GTS departments and a new academic quality of GTS in general has already been demonstrated in the US, and tomorrow Alec Patterson, our honoured guest speaker will present to us an overview of the impressive recent developments that have taken place in cardiac and particularly general thoracic science in the US.
The continuation of the described process will be crucial for the further position of general thoracic surgery. Unless our association will be able to offer GTS a fair position under the cardiothoracic umbrella and unless we will be able to create a reciprocal acceptance and appreciation, general thoracic surgery will further drift away from cardiac surgery, and ultimately might be swallowed by the heterogeneity of its existing forms. On the other hand the drift away of GTS would mean a substantial reduction in the abilities of cardiac surgery, not only for mutual influence, but also for the potential for a strong representation.
Ladies and gentleman, Francis Fontan has stated in his lecture here in Vienna that CTS is a speciality under threat. We have meanwhile observed an enormous consolidation and progress in our field and we can be more than proud of what we have achieved. However, we must keep in mind that we still are under threat and that we will have to remain alert and proactive.
Only if we succeed in avoiding the brain drain, the loss of the brightest minds from our specialty to other fields, and instead create conditions that will allow the brain gain, the attraction of our specialty to the most gifted and motivated young people, only then will we be able to guarantee a bright future.
I want to finish this lecture with a reflection on my personal position during the last year.
The post of a president can be seen in different ways. An American president has once stated "Being a president is like riding a tiger." I keep asking myself on which animal I have found myself. It certainly was not comparable to a tiger, however it is clear to me that it was one of the most enjoyable rides that I have ever had. Let me thank you for entrusting me with this position and for giving me this unique opportunity in my life.
References
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