Joint Council on Thoracic Surgical Education: an investment in our future.

The Joint Council on Thoracic Surgery Education, Inc, was established in 2008 with the mission ‘‘to advance thoracic surgery education.’’ The American Association for Thoracic Surgery (AATS), American Board of Thoracic Surgery (ABTS), Society of Thoracic Surgery (STS), and Thoracic Surgery Foundation for Research and Education were the 4 founding organizations that equally contributed to the creation of the Joint Council. The focus to date has been on resident and postgraduate thoracic surgery education. Current surgical residency models in the United States can be traced back to their origins at Johns Hopkins Universityattheturnofthe20thcentury.WilliamHalstedandWilliam Osler each contributed to the concept that surgical training was essentially an advanced apprenticeship model based on scientific foundation, defined structure, standardization of training, bedside and operating room teaching, graded responsibility, and residents at different levels working together. 1 Surgical training was initially pyramidal in design with multiple entering interns being exposed to a broad-based curriculum culminating in a few specialized surgical ‘‘chief’’ residents. The ‘‘master–apprenticeship’’ model persisted until the 1930s with the first formal residency in thoracic surgery being established at the University of Michigan in 1928 by John Alexander. This Hopkins resident education model was successful, but Edward Churchill at the Massachusetts General Hospital took the next steps forward with the recommendations to create a more rectangular organization structure for resident training. 2 Churchill emphasized most of the principles of surgical education that persist today: avoidance of exploitation of the intern, exposure to basic science, staff appointment to qualified surgical educators, flexibility in training when possible, graded responsibility, and the creation of an overall advisory board for graduate education. This led to the creation of the first Committee on Graduate Surgery Training in 1934 and the subsequent implementation of the American Board of Surgery in 1937, the Board of Thoracic Surgery in 1948, and the independent ABTS in 1971. This rectangular system succeeded in providing a broad-based surgical education to interested and committed residents and certainly met the needs of society after World War II whentheeconomybroadened,thepopulationgrew,medical knowledge exploded, technology improved, the demand for better health care expanded, and surgical specialization evolved. As a specialty, cardiothoracic surgery was in its infancy after World War II. We were in an age of clinical experimentation and reporting, we created surgical societies for continuing medical education, and there was little governmental or societal regulation. The creative environment after the war was intense, and no surgical specialty grew more dramatically than cardiothoracic surgery. The amalgam of bright minds, daring personalities, and new technologies such as cardiopulmonary bypass (1953) expanded the specialty beyond lung and esophageal disease and fueled a new cardiac surgical profession. New operations for congenital heart disease, valvular heart disease, and atherosclerotic heart and aortic disease and transplantation were conceived and implemented in avery short historical time period. Thoracic surgery also expanded, although somewhat later, with the introduction of endoscopic surgery, lung volume reduction surgery, and lung transplantation. With the signing of the Social Security Act of 1965, Medicare and Medicaid were established to pay for operations such as coronary artery bypass grafting, pulmonary resection for cancer, and transplantation. The combination of a bright and expanding future, little competition, high societal esteem, and excellent remuneration attracted the best and the brightest of surgical minds and hands to cardiothoracic surgery. Well-recognized surgical leaders then came out of leading cardiothoracic surgery institutions, such as Johns Hopkins, Duke University, Stanford University, and Cleveland Clinic. Cardiothoracic surgery was flourishing. Jump ahead a short 60 years to 2010. The future for cardiothoracic surgery is less certain with all sorts of real or perceived threats. We no longer seem to be attracting the best and brightest to our profession, residencies are going unmatched, more foreign medical graduates are applying for US residencies, and more graduating residents are failing both the ‘‘qualifying’’ and the ‘‘certifying’’ ABTS examinations. Intravascular technologies continue to evolve with the introduction of intracoronary artery stenting, thoracic endovascular stenting for larger vessel aortic disease, and now the potential for intravascular approaches to aortic and mitral valvular heart disease. Competing technologies and multiple alternative training algorithms are competing in our classic domains of care, and the surgical future of