Education, training and practice of cardiothoracic surgery

“An investment in knowledge pays the best interest” –

“Books must always follow Science, not science books”

“Everything should be made as simple as possible, but not simpler” – Albert Einstein

Over the past decade or so, several events have significantly impacted healthcare in general and cardiothoracic surgery in particular. Societal and demographic changes have contributed to a chronic shortage of candidates for cardiothoracic surgical training programs. In addition, the limitations on work hours for physicians-in-training (i.e., residents, fellows and registrars) have reduced the time spent in managing patients and the volume of cases seen, discussed, studied or operated upon. In some cases, such surgeons in training seek experience in institutions beyond their training locations. The increasing number of novel procedures such as catheter-based and minimally invasive interventions has further reduced the number of traditional “open” procedures. Especially in these procedures, the rapidly expanding role of cardiologists and interventional radiologists has further reduced clinical exposure and expertise, as in the case of aortic and valvular interventions. Furthermore, the current generation of cardiothoraic surgery trainees has been much more focused on bolstering their technical operative skills, as opposed to critical care skills. This reduced expertise has contributed to a decrease in the pass rate in some certification/credentialing examinations, thereby calling in question the competency of some candidates.

Partly for the same reason, there has been increasing reliance on the recrtuitment, employment and retention of mid-level “cardiac surgery providers”; i.e., nurse practitioners and physician assistant, to ‘fill in the gaps’ due to the reduced number of residents and fellows. Such clinicans now have a ubiquitious presence in all phases of patient management, from the outpatient clinic, preoperative evaluation to discharge. Another reason for the hiring of these non-surgeons is the financial appeal of employing clinicians seen as “fairly equal” to surgeons at a lower cost; as is the case of staffing of cardiothoracic surgical intensive care units clearly demonstrates. The introduction of a simplified or “watered down” educational and training curriculum for such clinicians has significantly reduced the knowledge base necessary for safe practice in such high-risk clinical areas and thus jeopardizes the foundation for safe practice.

The introduction of such abridged educational and training curriculum for clinicians charged with the bulk of cardiothroacic surgical practice has severely weakened the cause for surgeons engaging in continuing basic science or clinical research. New graduates face a situation where the “new normal” standards for practice are over-simplified, generalistic one-size-fits-all “guidelines” originally drafted for non-surgeons. This decreased interest has been made worse due to the much decreased impact of research findings on actual clinical practice or its guidelines, in favor of simplistic, often arbitrary policies drafted by administrators and bureaucrats, and expected to be implemented by such mid-level providers. This is reminiscient of the infamous quote “The Republic has no need for scientists”.

Due to the same regulatory and administrative considerations focused primarily on financial issues and the documentation of the bureaucratic paperwork, compounded by the absence of a clear and comprehensive credentialing process for cardiothoracic surgeons, cardiothoracic surgical critical care team leaders have been mostly non-surgeons who are “Critical Care-certified” in other specialties such as anæsthesiology or pulmonary medicine.

These changes have created an unprecedented situation on the ground (especially in cardiothoracic surgical critical care) where the cardiothoracic surgeon is ushered into practice with suboptimal education and training, to find himself/herself being considered equal to or be replaced outright by non-surgeon clinicians. Further worsening the frustration and humiliation is the fact that cardiothoracic surgeons have abdicated decisionmaking authority in critical care management to non-surgeons, while still being legally and administratively held accountable for patients’ outcomes in the critical care and postoperative period. Outside the critical care area, surgeons have been reduced to mere technicians performing a limited number of procedures, while facing increasingly firece competition from other specialties.

The unwelcome result of these changes has been the declining interest of medical students to pursue a career in cardiothoracic surgery, and a growing number of surgeons or surgeon candidates leaving the specialty in pursuit of other avenues of work. This is posing a significant existentional threat to the specialty and its professional identity.

Instead of becoming an endangered species, the governing organizations of cardiothoracic surgery are called upon to rise to the challenge of redefining their specialty as compatible with the 21st century, and to never relinquish this task to bureacrats or administrators whose only motivation is cost cutting. The return to the foundational principles and ethos of medical practice is urgently needed; where solid scientific findings, through rigiorous research, must be restored as the basis for education and training of surgeons. Financial considerations should be challenged to ensure proper definition of the role of each clinician involved in cardiothoracic surgery and cardiothoracic surgical critical care practice. Nurses, physician assistants and surgeons should be regarded as distinct groups of practitioners with different yet complementary backgrounds and skills. One isn’t and should never be a substitute for others.

In our specialty’s struggle for survival in today’s medical marketplace, our professional organizations should be inspired by the words of Admiral Sir Horatio Nelson to his naval troops demonstrating effective leadership, role definition and team resource management: “England Expects that Every Man Will do His Duty” To which we might add: “for which he/she has been properly educated, trained and credentialed.” n