Preparing the Next Generation of Residents to Care for Patients with Cardiothoracic Disease

Modern surgical education in the United States began in the 1890s under the direction of William Halsted, at the Johns Hopkins Hospital. The training program that he established for his surgical residents emphasized progressive responsibility and independence, culminating in senior experience as the operating surgeon.¹ Thoracic surgery's early organizational efforts resulted in the formation of the American Association for Thoracic Surgery in 1917, and the first thoracic surgery residency training program was established at the University of Michigan by John Alexander in 1928. World War II led to a maturation of the specialty, and in 1947 the Board of Thoracic Surgery was established as a subsidiary of the American Board of Surgery. The American Board of Thoracic Surgery (ABTS) became an independent board in 1971. The Thoracic Surgery Residency Review Committee (RRC) was founded in 1967, and the Thoracic Surgery Directors Association was founded in 1977. Many positive developments occurred subsequently, including the resident-matching program, a standardized curriculum, rigorous evaluation of training programs by the RRC, improvements to the ABTS examination process, and the formation of the Joint Council on Thoracic Surgery Education.

In recent years, several important challenges have presented themselves. The number of active cardiothoracic (CT) surgeons is declining, and the median age of active CT surgeons in the United States in 2010 was 52.9 years.² Given the projections for substantial growth in the population of patients over the age of 65 in the near future, there are dire predictions of a shortage of CT surgeons by 2020.³ The current work-hour restrictions negatively affect the operative experience of CT residents.⁴ There is a declining interest on the part of general surgery residents in pursuing a career in cardiothoracic surgery⁵; the demographics of medical students and residents are changing; there are changes in the expectations of students and residents concerning training and practice⁶; and we now recognize the need for improved evaluation of the surgical education process and of the residents who are completing training. Also, we must embrace the ongoing evaluation of practicing surgeons and the maintenance of their certification.

Thus far, there have been numerous positive responses to these challenges. Several of the leaders of our discipline have contributed thoughtful analyses of thoracic surgery education and specifically of how to conduct residency training programs.^7,8 The various CT surgery societies have undertaken extensive efforts to interest premedical and medical students, as well as general surgery residents, in CT surgery careers. We have also seen new emphasis on mentoring students and general surgery residents in order to stimulate their thinking about career opportunities in CT surgery—together with new emphasis on providing multiple pathways for the training of residents.

What is the route forward? Clearly, much more needs to be accomplished. First, we surgical educators must confront the concerns that have contributed to the declining interest in our profession, and we must better understand how the current generation views the world and their careers.⁹ We must identify and encourage students who are interested in what we do, and we must take the time to serve as their mentors and advisors.⁵ It is crucial that we be aware of the importance of role models, and we must transmit our own satisfaction and joy in doing what we do. It will be necessary to consider the special needs of women who are engaged in residency training. Innovations in curriculum design should be supported, along with an emphasis on educational enrichment through such techniques as surgical simulation. It will become necessary to design new tools that evaluate competence in a manner that helps us move away from our traditional emphasis on time in training and on numbers of cases. New methods of teaching that are more effective for the current generation of adult learners must be mastered. Even in a time of mandated work-hour restrictions, we have to teach responsibility and accountability for the patient's welfare.¹⁰ Despite the educational challenges imposed by the current emphasis on outpatient evaluations, early-morning admissions, and short lengths of stay—all of which impair the ability of the resident to form a personal bond with the patient—we must constantly remind our trainees that, in the words of Dr. Francis Peabody, “the secret of the care of the patient is in caring for the patient.”¹¹