Commentary: Marketing meets medical education

David L. Joyce, MD, MBA, FACS

Central Message.

Understanding the perspectives and preferences of medical students can promote more successful recruitment strategies for cardiothoracic surgery residency programs.

See Article page 509.

Amidst the alarming death toll of the coronavirus disease 2019 (COVID-19) pandemic, cardiovascular disease remains the leading killer.¹ Many of these cases can be treated with surgical interventions that are often some of the most technically demanding procedures in modern medicine. It follows that developing well-trained cardiothoracic surgeons is a matter of significant public health interest. Given that 100% of trainees originate in a medical school somewhere, it seems somewhat surprising that the types of recruitment strategies outlined in the manuscript by Axiaq and colleagues² aren't more prevalent. Despite the self-evident fact that students are unlikely to pursue a specialty to which they have never been exposed, many students complete their medical education without ever having set foot in a cardiothoracic operating room. Exposure is, of course, only the first step in the process. The leadership examples that are presented must be compelling and worthy of emulation. According to the data presented here, 22.2% of respondents had no exposure to cardiothoracic surgery, whereas fewer than 40 total respondents reported an “unenjoyable experience” within the specialty.² This suggests that exposure, rather than persuasion, represents the immediate challenge.

One useful framework for considering this problem comes from the 4 Ps and 3 Cs structure that marketing firms often use (Product, Price, Promotion, Place, Company, Customers, Competitors). In this model, there are several fixed variables. The product is a residency position in cardiothoracic surgery, the customers are the medical students who have yet to declare a specialty, and the company is the specialty itself. Although several attempts at price manipulation have occurred in recent years (the 80-hour workweek and integrated 6-year training models come to mind), the 10,000-hour rule has remained surprisingly resilient in defining the end point of a surgeon's technical mastery.³

That leaves 3 experimental variables, each of which present some intriguing possibilities. The authors suggest several strategies for promotion: mentorship, research opportunities, surgical teaching during cardiothoracic anatomy, and initiatives by the national societies.² This approach seems to view the “competition” as members of other specialties who are similarly engaged in these same types of recruitment efforts. However, if one considers the overall scale of the attention economy, competition for the best applicants extends to anything that occupies the focus of the target customer. Social media and streaming entertainment platforms begin to emerge as novel targets for both specialty promotion and candidate identification. Finally, as the postpandemic world begins to take shape, it may be worth considering a different distribution model. “Place” need not refer to the finite number of dedicated cardiothoracic operating rooms within a given academic institution. As undergraduate students increasingly demand semesters abroad, global health experiences like the ones offered at Tenwek Hospital in Bomet, Kenya, seem like an ideal opportunity to bring differentiation value to our specialty. All of this underscores the importance of discussing and understanding the types of data available in this important paper. A quantitative assessment of the problem, as demonstrated by this research group, serves as the first step in developing solutions.