Presidential address: thoracic surgery education—responding to a changing environment

Fred A. Crawford, Jr, MD I t is human nature to believe that the changes we witness and participate in are the most profound in history. In one lifetime, my grandfather witnessed a change in transportation from horseback to space travel and flights to the moon. In roughly the same 100 years, our specialty evolved from draining empyemas and a fear of even suturing the heart to repairing the most complex congenital defects, heart and lung transplantation, and even replacement of the heart with a mechanical device. Despite these advances, some fear that our specialty may be facing significant decline—even extinction—because of equally impressive advances by our colleagues, especially in cardiology. Bill Baumgartner, in his wonderful presidential address to The Society of Thoracic Surgeons (STS), described the changes occurring in our specialty and the opportunities afforded by these changes. Today I would like to discuss how these changes and the environment in which they are occurring are affecting our educational process and how cardiothoracic surgery education is evolving to respond to this changing environment. Please note that I chose the title “Thoracic Surgery Education” not “Thoracic Surgery Resident Education,” because surgical education is a continuous process extending from medical school through the postgraduate years. Because general and thoracic surgery education have been so closely intertwined, many of the issues important to one are also critical to the other. The American Association for Thoracic Surgery (AATS) was founded in 1917, and the first president was Samuel Meltzer, who stated in his presidential address, “The chief aims of the Association are the advancement of knowledge and skill in thoracic surgery.” He went on to say in the discussion, “I am confident that a time will come when thoracic surgery will be equal in importance to surgery of the abdomen.” One prospective member disapproved of the founding of the AATS, indicating that once empyema was cured, the association would dry up for lack of other topics. Instead, our specialty and the association have thrived. Today, 86 years later, we have a 5-day international meeting with multiple simultaneous sessions, a record 717 abstracts submitted, and 4389 attendees from 79 different countries. The first thoracic residency was established at Michigan by John Alexander in 1928. At the 1936 meeting of the AATS, in an article entitled, “The Training of a Surgeon Who Expects to Specialize in Thoracic Surgery,” Alexander stated that “two years of intensive study and practice in an active. . .thoracic surgery clinic are sufficient to take the examination of a board,” but went on to say that “a greater length of time would be desirable.” This 2-year training requirement was initiated when our specialty treated mostly empyema and tuberculosis. Predating the 80-hour work week requirements by 67 years, Alexander stated that his residents’ work “occupies an average of nine or ten hours a day during two years except for two vacations of a month each.” From the Department of Surgery, Medical University of South Carolina, Charleston, SC.