An endangered species
2009; Elsevier BV; Volume: 139; Issue: 1 Linguagem: Inglês
10.1016/j.jtcvs.2009.08.050
ISSN1097-685X
Autores Tópico(s)Cardiac, Anesthesia and Surgical Outcomes
ResumoI am indebted to many people for the opportunity to be a thoracic surgeon. First and foremost, I thank my family. My parents, Peggy and Charles, met as undergraduates at the University of Colorado and will celebrate their 58th wedding anniversary in September 2009. They taught me the importance of responsibility, perseverance, and hard work. I am grateful for the support they gave me as a student trying to go to medical school. My wife's parents, Neill and Miriam Farrington, have been an inspiration and strong role models. They will celebrate their 59th wedding anniversary in October. I am particularly grateful to my wife, Chris. Chris and I met as teenagers and have been married since the beginning of medical school. As my love and my best friend, she has always provided unwavering support and has been the bedrock of our family. Our sons, Patrick and Danny, have been incredibly understanding of the demands that our profession places on any family. I have benefited from priceless mentorship throughout my professional career. When I was a surgical resident at the University of Washington, Drs Tom Marchioro and Jim Carrico taught me the importance of being intellectually honest with myself to improve as a surgeon. Both were truly gifted surgical educators. Despite the rigors of their own careers, they made the education of residents their highest priority. Dr Marv Pomerantz (Figure 1, A) has been my friend and confidant for almost 20 years. Marv provides an excellent example for all to follow and inspires those around him to be the best they can be. His sage and calming advice is always welcome. Dr Fred Grover (Figure 1, B) has been an excellent role model with an unwavering commitment to the education of students and residents. He is the most patient and kind person I have ever met and is able to find the best of any situation and the best in people. The world needs more people like Fred. Like everyone who has ever worked with him, I wanted to be like Dr Alden Harken (Figure 1, C). His intellect, energy, charisma, and humor have combined to make him the world's greatest surgical educator. His passion for academic surgery has launched the careers of hundreds of young investigators. His unselfish desire to bask in the glory of those around him makes his friends and followers intensely loyal to him. He is one of the finest academic surgeons of our time. I owe him a great deal for the opportunities that he gave me. I have always had the privilege of working with truly talented colleagues and great residents. I have personally learned a great deal from working with them, and I thank them all. History teaches many valuable lessons for the present. One such lesson is that strategic action is required in difficult times. Such was the case in 1776, during the early phase of the American Revolution.1McCullough D. 1776. Simon and Schuster, New York2007Google Scholar The war started gloriously for the Americans. In the spring of 1775, the colonists routed the British at Lexington and Concord and claimed victory at Bunker Hill. Thereafter, the new Continental Army led by George Washington kept the British isolated in Boston with a successful siege for 6 months. Washington was victorious in the siege of Boston through a brilliant move of military strategy. He dispatched Henry Knox to retrieve abandoned artillery from Fort Ticonderoga in upstate New York and then secretly moved the cannon onto the Dorchester Heights, now part of South Boston. This gave the Americans military control of the city of Boston and forced the most powerful military force on earth to evacuate Boston by ship on March 17, 1776. Washington correctly anticipated that the British would next attack the city of New York. He therefore rapidly mobilized his forces to race to New York to arrive before the British. Bolstered by their victory at Boston, the colonists were flush with pride and overconfidence. Washington's men were cheered by the population, and legions of volunteers joined the Continental Army as it crossed the countryside en route to New York. While waiting in New York for the arrival of the British, Washington's army felt invincible and was eager to engage the British on Manhattan Island. But this glory was short-lived. With the arrival of 200 British warships in New York harbor in August 1776, the British gained control of the surrounding geography. By the end of August, the British had routed the Americans on Long Island; 2 weeks later, on September 14, 1776, the Americans were forced to evacuate New York City and Manhattan Island. The battles for New York were a disaster for the colonists. Nonetheless, knowing that the British would next move to take Philadelphia, Washington gathered his remaining troops and forced them to move as quickly as possible to protect that city. It seemed that the American Revolution would come to an end. Not only was the American army demoralized, but the defeat of the Americans at New York brought despair to the colonies. Assuming that the British would win the war, many prominent citizens renounced their allegiance to the patriots and signed oaths of loyalty to England. Included in this group were several members of the first Continental Congress. For a time, it seemed that the state of Maryland would renounce the Declaration of Independence. Americans turned away from the cause, and hundreds of American soldiers deserted daily. The British pursued the American army as it retreated from New York southward through New Jersey. In so doing, the British conquered the territory they covered. By the end of November 1776, the British controlled all of New Jersey. The only thing that separated them from Philadelphia was the Delaware River. With the British in pursuit, and his army dwindling, Washington escaped New Jersey by crossing the Delaware River into Pennsylvania on December 8, 1776. Brilliantly, he took all the boats on the New Jersey side of the river with him as he crossed the river. Knowing that the odds were very much against him, he did everything possible to position his army between the British and the city of Philadelphia. The British were confident that they had broken the back of the rebels. Unable to cross the Delaware River without boats, the British army halted their advance in New Jersey and hoped that the Delaware River would freeze so that they could then take Philadelphia. The American revolutionary cause was near extinction. December 1776 was a desperate time. Washington's exhausted army was starving, naked, and demoralized. The commissions of those soldiers who had not already deserted were set to expire 3 weeks hence on January 1, 1777. Very few indicated an intention to reenlist, and there were even fewer new recruits; Washington would have no army in a matter of days. The population had lost faith in the cause of the revolution and acquiesced to British rule. Washington knew that soon the Delaware River would be frozen, allowing the British troops to cross easily to take Philadelphia. At that juncture, the Americans would be defeated. The Americans were clearly at a point when the Revolution could fail. Considering his options, Washington decided that he must do something differently. He rejected the advice of his council to continue his retreat further into central Pennsylvania in the hope of attracting more recruits. Instead, he chose to be proactive. He made the astonishing and bold decision to divide his small force and to attack the British. I have come to believe that Washington came to this particular decision in large part because he recognized that unless he changed his course of action, he was doomed. Acknowledging his predicament, he chose to take the situation head-on and with an eye toward the future. This allowed him to determine the details of his situation and to recognize that he actually had necessary strengths. He recognized that the Germans mercenaries stationed at Trenton arrogantly thought that the Americans were no longer capable of putting up a fight. He knew that the British were so overconfident that they chose the comforts of the town of Princeton, away from the front. And he knew that on Christmas night, his opponents would be drunk and sleeping after their feasting. On Christmas night of 1776, he shuttled his is army of 2000 men, along with horses and cannon, back across the Delaware River and defeated the British at the Battle of Trenton. This victory gave a renewed sense of hope to the Americans. Thousands of men enlisted in the army, and once again the citizens believed in the cause. This strategic action was arguably the turning point of the war, and of American history. Today, it is thoracic surgical education that is in a difficult situation. I believe that we in thoracic surgery have arrived at a time in our history when we must act, and act now. Like the American Revolution, thoracic surgical education had a glorious beginning. Thoracic surgery was the next new thing, and everyone wanted to do it. Competition for thoracic surgical residency positions was keen; only the best and the brightest surgical residents were chosen. In any given hospital, the thoracic residents were the best doctors in the hospital. Not long ago, pictures of the thoracic surgical chief residents at Massachusetts General Hospital even hung in the lobby. No more. Today, as said by Winston Churchill during World War II, “the news from the front is bad.” We recognize our situation. We in thoracic surgery have had a growing sense of despair. As the threats to our specialty have progressively become tangible over the past decade, we have gone through Kübler-Ross's stages of grief: denial, anger, bargaining, and depression. I now fear that we have been desensitized to our situation and have reached the fatal level of acceptance of our fate. We are all familiar with the data: the number of applicants to Thoracic Surgical residencies has fallen steadily since 1995. This year, in fact, there were 97 total applicants for 118 positions, and only 67 were graduates of U.S. medical schools. The thoracic surgical resident is now an endangered species, and if this trend continues, it will become extinct. The decline in thoracic surgical residents has in turn led to a loss in the number of institutions with thoracic surgical training programs, down more that 20% since 2002 (Figure 2). This represents an erosion and ultimate loss of the infrastructure needed for thoracic surgical education. Once this infrastructure is gone, it will be extremely difficult, if not impossible, to regenerate. In my opinion, the endangerment of the thoracic surgical resident is the single greatest threat to our entire specialty. Many reasons have been put forward to explain our endangerment. Professional reimbursement has changed, suggesting to some that that society no longer values what we do. New technologies may now be used to treat diseases of the chest, and our specialty lacks the skills necessary to embrace the technologies. Student debt is excessive. People don't want operations, and some infer the end of days for surgery. The job market is tight. Although there is certainly some truth to each of these statements, I think that it has become all too easy to use them as excuses. In my opinion, these factors and others must be acknowledged, and we must take them head-on. But these same factors apply to all specialties. They are not unique to thoracic surgery, yet it is specifically the thoracic surgical resident that is endangered. In fact, while the number of first-year thoracic surgical residents decreased 24% between 2002 and 2007, the corresponding numbers increased by 15% in plastic surgery, 21% in urology, 31% in vascular surgery, and 52% in neurosurgery.2McDonald K. Sutton J. Surgical workforce: an emerging crisis.Bull Am Coll Surg. 2009; 94: 21-26PubMed Google Scholar We in thoracic surgery must begin to take responsibility for this situation and to act proactively. To attribute our problems to someone else or to circumstances that we simply cannot control is the hallmark of defeat. We have dedicated our professional careers to the greatest field in all of medicine, and we have arrived at a turning point. We must act now. I find this decline in thoracic surgery applicants to be ironic. Thoracic Surgery will certainly change, but it is not going away. The facts of the matter are these. First, the number of Thoracic Surgical procedures continues to grow. Second, by all accounts, a shortage of thoracic surgeons is on the immediate horizon. First, the surgical data. It is true that during the past decade, the number of coronary artery bypass grafting operations has decreased by approximately 25% nationally. Medicare claims data indicate that this trend has slowed significantly during the last 6 years, however, suggesting that the decline in bypass volumes may be ending. At the same time, the number of aortic valve operations has increased by 28%. The number of mitral valve operations has increased by 24%. The number of pulmonary resections has increased by 25%. The number of aortic procedures has risen by 28%. The number of mechanical assist devices is up at least 100%. With the exception of coronary artery bypass grafting, billing for virtually every thoracic surgical Current Procedural Terminology code has increased in volume during the past 5 years.3Jancin G. Workforce dilemma challenges thoracic surgery.Thorac Surg News. 2007; 3 (1 (May/June))Google Scholar, 4Ailawadi G, Kron I. The challenges facing cardiothoracic surgeons. Vasc Dis Manage [Internet]. 2007 Nov [cited 2009 June 6];4(6). Available at: www.vasculardiseasemanagement.com/article/8080Google Scholar, 5Society of Thoracic Surgeons national cardiac surgical database. Chicago: Society of Thoracic Surgeons. c2008 [cited 2009 June 10]. Available at: http://www.sts.org/sections/stsnationaldatabase/Google Scholar, 6Barnett S.D. Ad N. Surgery for aortic and mitral valve disease in the United States: a trend of change in surgical practice between 1998 and 2005.J Thorac Cardiovasc Surg. 2009; 137: 1422-1429Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Yes, the case mix of thoracic surgical practice does look different, but these changes offer exciting opportunities for continued growth. Furthermore, advances in the molecular therapies of thoracic malignancies will almost certainly increase the number of pulmonary and esophageal resections by converting the unresectable into the resectable. New endovascular techniques have already expanded the ability to treat diseases of the thoracic aorta. Clearly there is plenty of work to do, and it seems to be growing. Second, all workforce projections suggest a significant undersupply of thoracic surgeons within the next 10 years.3Jancin G. Workforce dilemma challenges thoracic surgery.Thorac Surg News. 2007; 3 (1 (May/June))Google Scholar According to the Association of American Medical Colleges, more than 50% of currently practicing thoracic surgeons are older than 55 years, and at least 15% are older than 65 years. Survey data from the Society for Thoracic Surgery and American Association of Thoracic Surgeons strongly imply that more than half of the currently practicing thoracic surgical workforce will retire within the next 12 years.3Jancin G. Workforce dilemma challenges thoracic surgery.Thorac Surg News. 2007; 3 (1 (May/June))Google Scholar, 4Ailawadi G, Kron I. The challenges facing cardiothoracic surgeons. Vasc Dis Manage [Internet]. 2007 Nov [cited 2009 June 6];4(6). Available at: www.vasculardiseasemanagement.com/article/8080Google Scholar The seriousness of this decline is exacerbated by the fact that the population is aging. Thoracic surgical diseases tend to increase in prevalence with age. In 2010, approximately 13% of the U.S. population will be older than 65 years. By 2030, this figure will grow to 20%.4Ailawadi G, Kron I. The challenges facing cardiothoracic surgeons. Vasc Dis Manage [Internet]. 2007 Nov [cited 2009 June 6];4(6). Available at: www.vasculardiseasemanagement.com/article/8080Google Scholar Thus the demand for thoracic surgical procedures will continue to grow. With the need for thoracic surgeons strong, growing, and projected to grow even more as the populations ages, all workforce projections predict a significant shortage of thoracic surgeons within the next 10 years. So not only is there plenty of work to do, with the amount of work growing, but there will soon be no one left to do it. The economic laws of supply and demand suggest that market forces will dictate rising professional opportunities for those practicing thoracic surgery as the workforce shrinks. Today is the perfect time to get in. These data should be seen as a tremendous opportunity for young physicians. Why, then, are so few interested in pursuing it? To answer this question, I think we need to take a hard look in the mirror. In my opinion, there are 3 major reasons. First, thoracic surgery is hard. I am reminded of a conversation that I recently had with a medical student, who scrubbed in during a valve operation. At the end of the procedure, I asked the student what he thought. “That was the coolest thing I have ever seen,” he exclaimed. Postoperatively, as we sat together in the intensive care unit talking about the patient's physiology, I said “Have you thought about being a heart surgeon?” He replied, “I don't think so—it's too much work. It's too hard”. Without thinking, I reflexively responded to him with the lines spoken by the actor Tom Hanks in the movie A League of Their Own. I said, “It's supposed to be hard. If it wasn't hard, everyone would do it. The hard is what makes it great.” Thoracic surgery is hard, and in my opinion we need to stop apologizing for that. The truth of the matter is that it has always been hard–this is nothing new. If anything, it is easier today than ever. The inherent nature of thoracic surgery lies in dealing with difficult problems, and it will therefore always be hard. Despite recognition of the rigors of thoracic surgery, unfortunately, our collective approach has been to try to water down the specialty to avoid this criticism. The right people to do our specialty are out there. Somehow, we've begun to act like victims and to wait for applicants to come to us. Instead, we need proactively to seek out and find the right people. Second, there is strong evidence that thoracic surgical education in its current form is not working well. There is widespread dissatisfaction with the product of our residency programs among thoracic surgical faculties. These subjective feelings are supported by the data. The recent performances of the graduates of our programs on the qualifying and the certifying examinations given by American Board of Thoracic Surgery have been poor. For each of the last 4 years, at least 20% have failed the written examination. Among those who passed the written examination and went on to take the oral examination, nearly 30% have failed in each of the last 3 years. This year, 31% of those taking the oral examination for the first time failed. When speaking of such Board score performance as a parameter of the quality of Thoracic Surgical education, it is easy to blame the students. I actually think, however, that it reflects more on the teachers than on the students. This speaks to the third reason, which is the most important. As Winston Churchill said, “We occasionally stumble over the truth, but most of us pick ourselves up and hurry off as if nothing had happened.” At the core of the problem is the fact that we collectively have lost our moral compass as teachers. It has become far too easy in too many programs to view the thoracic surgical resident more as an indentured servant than as a student and a future colleague. Years ago, Dr Shumway said, “The hardest thing about cardiac surgery is getting to do it.” Judging by the research presented at last year's meeting in Hawaii by John Doty, this statement holds more truth today than ever.7Connors R.C. Doty J.R. Bull D.A. May H.T. Fullerton D.A. Robbins R.C. Effect of work-hour restriction on operative experience in cardiothoracic surgical residency training.J Thorac Cardiovasc Surg. 2009; 137: 710-713Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar The teachers of thoracic surgery are the “keepers of the flame” of the specialty. We should be the champions of the future generation of surgeons. Sadly, the feedback from our residents about the job we are doing as teachers of thoracic surgery is disheartening. Associated with the decline in the number of thoracic surgical applicants, the feedback from those residents who have entered thoracic surgical residencies has been damning. Surveys conducted by the Thoracic Surgery Resident Association have indicated that as many as 70% of respondents believed that the program director did not help them in finding a job. Forty percent said that they would choose a different program. More than 25% of thoracic surgical residents said that they would choose a different career. Fifty-two percent said that they would not recommend cardiothoracic surgery to potential resident applicants.8Lee R. Help wanted.Ann Thorac Surg. 2003; 76: 1779-1781Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 9Salazar J.D. Ermis P. Laudito A. Lee R. Wheatley 3rd, G.H. Paul S. et al.Cardiothoracic surgery resident education: update on resident recruitment and job placement.Ann Thorac Surg. 2006; 82: 1160-1165Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar Because our residents that should be the greatest pride of our profession, and therefore the best advertisements for our residency programs, it should be no surprise that applications are falling. I believe residents' lack of enthusiasm is the root cause of the declining applicant pool. Why would anyone choose a specialty in which the current residents did not feel supported, were demoralized for 2 to 3 years, and then went on to fail their Boards? In his book How the Mighty Fall,10Collins J. How the mighty fall. Harper Collins, New York2009Google Scholar Jim Collins described the characteristics of great enterprises that fail. He contrasted these with the actions of those enterprises that prevent themselves from failing. He has found that the road to failure begins with the loss of an understanding of the factors that created success in the first place and of what it takes to remain successful. Instead, success becomes regarded “as an entitlement.” In other words, failure begins with the loss of a corporate moral compass. His research further indicated that the decline of an enterprise is typically self-inflicted; however, great enterprises do have the capacity to self-correct. When poised to fall, they can prevent failure and in some cases recover to become even greater that they had once been. In my opinion, these principles apply to thoracic surgical education. Not only must we collectively regain our moral compass, we must reengineer the way we train people to be thoracic surgeons. For a long time, the essence of thoracic surgery has remained fairly constant. But as Andrew Grove11Grove A.S. Only the paranoid survive: how to exploit the crisis points that challenge every company. Doubleday, New York1996Google Scholar wrote, “Sooner or later something fundamental in your business world will change.” This process of change has been manifest in industry forever. Successful enterprises must be able to see and understand such changes to adapt. When the environment changes, an organism, company, or surgical specialty must change its phenotype to survive. Failure to do so leads to extinction. Whether in nature, the corporate world, or a surgical specialty, it is ultimately forces of competition that drive the changes in the phenotype of an enterprise. Thirty years ago, Porter12Porter M.E. On competition. Harvard Business School Publishing, Boston2008Google Scholar described the major competitive forces that are exerted on a business enterprise that force a phenotypic change. According to Porter,12Porter M.E. On competition. Harvard Business School Publishing, Boston2008Google Scholar a business enterprise is subjected to external forces such as the vigor of a business competitor or the viability of a business supplier. All corporate entities must reach some steady state as these forces are balanced. If one or more of these external forces reaches sufficient magnitude, it threatens the viability of the enterprise. When this happens, the enterprise must change the way that it does business, its phenotype, to remain viable (Figure 3). The mechanisms by which this process of transition from one phenotype to the next occurs determine whether the enterprise thrives. In his book Only the Paranoid Survive, Andrew Grove11Grove A.S. Only the paranoid survive: how to exploit the crisis points that challenge every company. Doubleday, New York1996Google Scholar describes this transition process from the old way of doing business to the new as a “strategic inflection point.” He describes this as a time in the life of an enterprise when its fundamentals are about to change. After this change, the enterprise will either flourish or fail. According to Grove, such a strategic inflection point leads to a full-scale change in the way that the enterprise conducts its business. Grove also notes that it is difficult to know just when a strategic inflection point occurs, even in retrospect. The recognition may take place in stages. As Grove indicated, first, there is a sense that something is different. Customers treat you differently. Trade shows are weird. Competitors who you once ignored take business from you. When the early signs of a strategic point are noted, one can't be sure that they are necessarily important.11Grove A.S. Only the paranoid survive: how to exploit the crisis points that challenge every company. Doubleday, New York1996Google Scholar At some point, however, the existence of the strategic inflection point is incontrovertible. Whether an enterprise lives or dies after a strategic inflection point is determined by how it manages this transition. Because it is by definition difficult to know just what to do to become the “phenotype of the future,” the transition from the old to the new can be perilous. According to Grove,11Grove A.S. Only the paranoid survive: how to exploit the crisis points that challenge every company. Doubleday, New York1996Google Scholar dissenting ideas about the right direction to go split people on the same team. There is a growing ferocity, determination, and seriousness surrounding the views of various participants. Divergent views are held strongly, like religious tenets. Wars erupt between long-term friends and colleagues. I believe that thoracic surgery education is going through such an inflection point. As Grove described, it is difficult to pinpoint just when it began. But clearly and unmistakably, things have changed. To understand why thoracic surgical education is of paramount importance, we must first address thoracic surgery as a specialty. Thoracic surgery is big and powerful. It financially drives the American hospital system. Like all big, powerful businesses it has attracted the attention of people who want a piece of that business. This fact motivates the development of one of the most potent external forces of phenotypic change, the threat that the business you are doing can be done differently.11Grove A.S. Only the paranoid survive: how to exploit the crisis points that challenge every company. Doubleday, New York1996Google Scholar In thoracic surgery, there are many examples of this threat manifested in a variety of different ways. To name a few: thoracoscopy done by pulmonologists, pneumothorax treated by emergency department physicians, esophageal cancer treated without resection, thoracic aortic aneurysm treated by endovascular stents, lung cancer treated with radiofrequency ablation, coronary artery disease treated with coronary artery stents, valvular heart disease treated by percutaneous techniques. These are examples of external forces that are driven primarily by technologies and skills possessed or acquired by other medical specialties. In addition, however, our specialty is changing from one of vertical integration to one of horizontal integration. From its onset, and through its heritage, the treatment of thoracic surgical diseases was vertically integrated. Each step in the care of a thoracic surgical patient came sequentially, and each function was performed by a thoracic surgeon. Thoracic surgeons made the diagnosis of chest disease, staged it, and determined whether an operation was indicated. Only our specialty performed the operative procedures. Postoperatively, thoracic surgeons cared for thoracic surgical patients in the intensive care unit setting, cared for them on the postoperative ward, and provided longitudinal follow-up of thoracic diseases. Finally, the quality of thoracic surgical care was completely within the domain of thoracic surgeons; thoracic surgeons alone decided what was and was not good quality thoracic surgical care (Figure 4). Whether we like it or not, the treatment of thoracic diseases is changing to become horizontally integrated (Figure 5). The diagnosis of chest diseases is made not only by thoracic surgeons but by cardiologists, internists, and radiologists. The preoperative evaluation and staging of the thoracic surgical patient is now conducted not only by a thoracic surgeon but by an internist, cardiologist, pulmonologist, or anesthesiologist. No longer are thoracic surgical procedures the exclusive domain of the thoracic surgeon. Vascular surgery, cardiology, interventional pulmonology, interventional radiology, and emergen
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