Education or training in cardiothoracic surgery

The Thoracic Comprehensive Curriculum Document promulgated by the Thoracic Surgery Directors Association provided a first attempt to define in detail the content of cardiothoracic surgical education. The goals were to guide instruction by faculty, learning by residents, and to provide a basis for program evaluation. This was a thoughtful step in the evolution of residency programs from the “pot luck” approach of teaching the resident by precept and experience based on whatever was the clinical mass and distribution of patients in a given unit. The history is long of the evolution of training requirements from total number of cases performed to insistence upon breadth of experience across the spectrum of cardiac and general thoracic surgery. This matter became particularly acute a few decades ago when the dominance of thoracic surgery by the burgeoning of adult cardiac surgery was so overwhelming that general thoracic surgical education became alarmingly attenuated. The rather primitive mechanism of case type quotas was instituted by the Board as necessary to begin some restoration of educational balance in residency programs. Thus, tension inherent in the broadly defined specialty of thoracic surgery among its components of general thoracic surgery, adult cardiac surgery, and congenital cardiac surgery militated in favor of a broadly based education, bringing with the technical knowledge varied physiology and pathology. I use the word tension to indicate forces at work rather than in an adversarial sense. A further tension in designing a residency program arises between a desire on one hand to codify each detail of content versus the take-it-as-it-comes approach originally used. Cardiothoracic surgical training programs vary greatly in content depending on the particular history of an institution, the interests of its staff, its flow of patients, and other factors determined outside the educational domain. The efforts of the Board of Thoracic Surgery and of the Residency Review Committee have been notable in bringing some conformity to these natural variations and in assuring that candidates for training receive a reasonably broad and preferably deep education in many aspects of cardiothoracic surgery. The goal of the Board is fundamentally to certify surgeons who will practice their specialty knowledgeably and safely. The goal, therefore, is a pragmatic one. The Thoracic Surgery Directors Association has moved on to a proper consideration of the total educational experience deemed appropriate for a thoracic surgeon. The present survey has twin goals of measuring perceived adequacy of instruction in the Curriculum, which was outlined and, further, its relevance to individual practice [1]. Thus, it is a report of consumer satisfaction and opinion. “Relevance to practice” is a wholly pragmatic yardstick. It is, therefore, not surprising that the objectives most relevant to practice mirror the predominant adult cardiac surgical practices (65%) of those surveyed; 62% of “most relevant” items were related to adult cardiac surgery. By the same measure, the least relevant subjects, as might be expected, include congenital heart problems, transplantation, esophageal physiology, and tracheal surgery. Because each of these areas is likely to be managed to great extent by a relatively few surgeons, relevancy to practice scores were low overall.