Ann Thorac Surg 2015;99:1875–8
LANDMARK ARTICLE COMMENTARIES ON OLDHAM ET AL (1971), CAVES ET AL (1973), AND SLOAN (1975)
1877
50TH ANNIVERSARY LANDMARK COMMENTARY ON SLOAN H. THE BREEDING AND FEEDING OF THORACIC SURGEONS. ANN THORAC SURG 1975;20:371–86 In his 1975 The Society of Thoracic Surgeons Presidential Address, “The Breeding and Feeding of Thoracic Surgeons,” Dr Herbert Sloan presented his views on thoracic surgery in the United States, specifically regarding (1) training, (2) workforce needs, and (3) continuing education and evaluation of clinical competence [1]. Understandably, having served on The American Board of Thoracic Surgery (ABTS) for 20 years, longer than any other thoracic surgeon before or since, he equated progress in residency training with the developmental milestones of this organization: establishment of The Board of Thoracic Surgery as an affiliate of The American Board of Surgery (1948), assumption of the responsibility for evaluating training programs by the Residency Review Committee (1967), abandonment of affiliate status by The Board of Thoracic Surgery as it became a primary board (1968), the name change to The American Board of Thoracic Surgery (1971), and concern about the 30% to 100% failure rate on the Board examination, leading to establishment of both minimum case requirements and distribution in accredited programs. His pride in the achievements of the ABTS was the stimulus for his meticulous accounting of the Board’s 50-year history [2]. I was privileged to know Dr Sloan as a mentor, friend, and colleague for 40 years. As a strong personality and editor of The Annals of Thoracic Surgery for 15 years, he honed his critical communication skills. Hearing that a patient had undergone “multiple thoracic surgeries” would engender his ire as he would correct, “You mean multiple thoracic operations . . . surgery is a discipline, operation is a procedure!” Now, years later, I find myself experiencing that same “sound of chalk on the blackboard” response to the phrase that pervades Dr Sloan’s address: “thoracic training programs.” Our specialty has become increasingly aware that “training” and “education” are not synonymous, the former representing know how, the latter, know why. A commonly heard current phrase is, “You train dogs and horses; you educate residents!” In 1975, the high failure rate on the Board examination was attributed in part to the fact that more than half of the applicants were foreign medical graduates and had been provided poor clinical experience in many programs. With greater focus on postgraduate education since Dr Sloan’s address, the Accreditation Council for Graduate Medical Education has mandated in accredited programs more than “case numbers”—with a greater emphasis on didactic teaching, the evaluation process of both the residents and faculty, and scholarly activities. Growing concern again about the nearly 30% failure rate on the ABTS qualifying (oral) examination in recent years [3] has called into question the quality of residency education. That the 80-hour work week mandate may be contributing to the rising failure rate on the oral examination by decreasing the experiential learning of the resident has also been suggested [4]. This issue is now being addressed by the enormous combined efforts of the Thoracic Surgery Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Directors Association, the Residency Review Committee, and the Joint Council on Thoracic Surgery Education to develop a structured curriculum based on established principles of learning, including ample simulation training and structured mock patient encounters. In his address, Dr Sloan expressed his strong belief that with the near zero population growth in the United States, “the number of new thoracic surgeons trained and certified each year must be limited,” and he urged that the specialty, not the federal government, control this. Though well-intended, this position did not resonate well outside of our specialty, where the Sherman Antitrust Act prohibits such “anticompetitive” activities by a trade or business organization. But other forces that Dr Sloan did not anticipate have constrained our job market. Alternative treatments for coronary artery disease have evolved. The number of approved residency programs in thoracic surgery has declined. A substantial number of first-year positions in the traditional residency programs were not filled. The thoracic surgery workforce has an average age of 53 years, and it is anticipated that half of currently practicing thoracic surgeons will retire within 12 years [5]. The number of new certificates issued by the ABTS decreased from 126 in 2000 to 93 in 2011. The production of new thoracic surgeons will not keep pace with the number retiring. Dr Sloan predicted in 1975 that at the existing rate of 150 to 200 new ABTS certificates per year, in 25 more years there would be 4,000 “card-carrying thoracic surgeons in the US.” Now 40 years later, there are only 4,261 diplomates of the ABTS (personal communication with the ABTS office). But all is not lost! The aging United States population, with its burden of cardiovascular disease, lung, and esophageal cancer, will create an enormous demand for cardiothoracic surgeons. The new integrated thoracic surgery residency paradigm provides an option for meeting the anticipated demand by shortening the overall length of residency to 6 years and accepting residents directly from medical school. Medical students have responded favorably. There are now 65 traditional residency programs and 26 integrated programs [6]. Finally, Dr Sloan championed the need for continuing education and evaluation of clinical competence. “If you don’t continue to educate yourself, you face partial obsolescence in 5 to 10 years . . .” He urged that the specialty prepare itself for mandatory recertification. His words were prophetic. In 2008 the ABTS replaced its recertification process with the Maintenance of Certification (MOC) process, an assurance to the public that we are maintaining high standards of clinical care throughout our careers [7]. Dr Herbert Sloan’s landmark 1975 The Society of Thoracic Surgeons Presidential Address reflected his deep commitment to the specialty of thoracic surgery and to the quality care of our patients. I believe that he would approve of the fact that in 2015, training, breeding, and feeding thoracic 0003-4975/$36.00
1878
LANDMARK ARTICLE COMMENTARIES ON OLDHAM ET AL (1971), CAVES ET AL (1973), AND SLOAN (1975)
surgery residents have been replaced with educating, mentoring, and developing the next generation. Mark B. Orringer, MD Section of Thoracic Surgery University of Michigan 1500 E. Medical Center Dr Ann Arbor, MI 48109 e-mail: [email protected] http://dx.doi.org/10.1016/j.athoracsur.2015.04.069
References 1. Sloan H. The breeding and feeding of thoracic surgeons. Ann Thorac Surg 1975;20:371–86.
Ann Thorac Surg 2015;99:1875–8
2. Sloan H. The American Board of Thoracic Surgery. A 50 year perspective. Evanston, IL: The American Board of Thoracic Surgery; 1998. 3. The American Board of Thoracic Surgery. Certification-5 year exam pass/fail rate. Available at https://www.abts.org/root/ home/certification.aspx. 4. Moffatt-Bruce SD, Ross P, Williams TE Jr. American Board of Thoracic Surgery examination: fewer graduates, more failures. J Thorac Cardiovasc Surg 2014;147:1464–9. 5. Shemin R, Ikonomidis JS. Thoracic Surgery Workforce: report of STS/AATS Thoracic Surgery Practice and Access Task Force—snapshot 2010. Ann Thorac Surg 2012;93:348–55. 6. Accreditation Council for Graduate Medical Education (ACGME) - Public List of ACGME Accredited Programs and Sponsoring Institutions. Available at https://www.acgme.org/ ads/public. 7. American Board of Thoracic Surgery. Maintenance of certification. Available at https://www.abts.org/root/home/ maintenance-of-certification.aspx.
LANDMARK ARTICLE COMMENTARIES ON OLDHAM ET AL (1971), CAVES ET AL (1973), AND SLOAN (1975)
1877
50TH ANNIVERSARY LANDMARK COMMENTARY ON SLOAN H. THE BREEDING AND FEEDING OF THORACIC SURGEONS. ANN THORAC SURG 1975;20:371–86 In his 1975 The Society of Thoracic Surgeons Presidential Address, “The Breeding and Feeding of Thoracic Surgeons,” Dr Herbert Sloan presented his views on thoracic surgery in the United States, specifically regarding (1) training, (2) workforce needs, and (3) continuing education and evaluation of clinical competence [1]. Understandably, having served on The American Board of Thoracic Surgery (ABTS) for 20 years, longer than any other thoracic surgeon before or since, he equated progress in residency training with the developmental milestones of this organization: establishment of The Board of Thoracic Surgery as an affiliate of The American Board of Surgery (1948), assumption of the responsibility for evaluating training programs by the Residency Review Committee (1967), abandonment of affiliate status by The Board of Thoracic Surgery as it became a primary board (1968), the name change to The American Board of Thoracic Surgery (1971), and concern about the 30% to 100% failure rate on the Board examination, leading to establishment of both minimum case requirements and distribution in accredited programs. His pride in the achievements of the ABTS was the stimulus for his meticulous accounting of the Board’s 50-year history [2]. I was privileged to know Dr Sloan as a mentor, friend, and colleague for 40 years. As a strong personality and editor of The Annals of Thoracic Surgery for 15 years, he honed his critical communication skills. Hearing that a patient had undergone “multiple thoracic surgeries” would engender his ire as he would correct, “You mean multiple thoracic operations . . . surgery is a discipline, operation is a procedure!” Now, years later, I find myself experiencing that same “sound of chalk on the blackboard” response to the phrase that pervades Dr Sloan’s address: “thoracic training programs.” Our specialty has become increasingly aware that “training” and “education” are not synonymous, the former representing know how, the latter, know why. A commonly heard current phrase is, “You train dogs and horses; you educate residents!” In 1975, the high failure rate on the Board examination was attributed in part to the fact that more than half of the applicants were foreign medical graduates and had been provided poor clinical experience in many programs. With greater focus on postgraduate education since Dr Sloan’s address, the Accreditation Council for Graduate Medical Education has mandated in accredited programs more than “case numbers”—with a greater emphasis on didactic teaching, the evaluation process of both the residents and faculty, and scholarly activities. Growing concern again about the nearly 30% failure rate on the ABTS qualifying (oral) examination in recent years [3] has called into question the quality of residency education. That the 80-hour work week mandate may be contributing to the rising failure rate on the oral examination by decreasing the experiential learning of the resident has also been suggested [4]. This issue is now being addressed by the enormous combined efforts of the Thoracic Surgery Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Directors Association, the Residency Review Committee, and the Joint Council on Thoracic Surgery Education to develop a structured curriculum based on established principles of learning, including ample simulation training and structured mock patient encounters. In his address, Dr Sloan expressed his strong belief that with the near zero population growth in the United States, “the number of new thoracic surgeons trained and certified each year must be limited,” and he urged that the specialty, not the federal government, control this. Though well-intended, this position did not resonate well outside of our specialty, where the Sherman Antitrust Act prohibits such “anticompetitive” activities by a trade or business organization. But other forces that Dr Sloan did not anticipate have constrained our job market. Alternative treatments for coronary artery disease have evolved. The number of approved residency programs in thoracic surgery has declined. A substantial number of first-year positions in the traditional residency programs were not filled. The thoracic surgery workforce has an average age of 53 years, and it is anticipated that half of currently practicing thoracic surgeons will retire within 12 years [5]. The number of new certificates issued by the ABTS decreased from 126 in 2000 to 93 in 2011. The production of new thoracic surgeons will not keep pace with the number retiring. Dr Sloan predicted in 1975 that at the existing rate of 150 to 200 new ABTS certificates per year, in 25 more years there would be 4,000 “card-carrying thoracic surgeons in the US.” Now 40 years later, there are only 4,261 diplomates of the ABTS (personal communication with the ABTS office). But all is not lost! The aging United States population, with its burden of cardiovascular disease, lung, and esophageal cancer, will create an enormous demand for cardiothoracic surgeons. The new integrated thoracic surgery residency paradigm provides an option for meeting the anticipated demand by shortening the overall length of residency to 6 years and accepting residents directly from medical school. Medical students have responded favorably. There are now 65 traditional residency programs and 26 integrated programs [6]. Finally, Dr Sloan championed the need for continuing education and evaluation of clinical competence. “If you don’t continue to educate yourself, you face partial obsolescence in 5 to 10 years . . .” He urged that the specialty prepare itself for mandatory recertification. His words were prophetic. In 2008 the ABTS replaced its recertification process with the Maintenance of Certification (MOC) process, an assurance to the public that we are maintaining high standards of clinical care throughout our careers [7]. Dr Herbert Sloan’s landmark 1975 The Society of Thoracic Surgeons Presidential Address reflected his deep commitment to the specialty of thoracic surgery and to the quality care of our patients. I believe that he would approve of the fact that in 2015, training, breeding, and feeding thoracic 0003-4975/$36.00
1878
LANDMARK ARTICLE COMMENTARIES ON OLDHAM ET AL (1971), CAVES ET AL (1973), AND SLOAN (1975)
surgery residents have been replaced with educating, mentoring, and developing the next generation. Mark B. Orringer, MD Section of Thoracic Surgery University of Michigan 1500 E. Medical Center Dr Ann Arbor, MI 48109 e-mail: [email protected] http://dx.doi.org/10.1016/j.athoracsur.2015.04.069
References 1. Sloan H. The breeding and feeding of thoracic surgeons. Ann Thorac Surg 1975;20:371–86.
Ann Thorac Surg 2015;99:1875–8
2. Sloan H. The American Board of Thoracic Surgery. A 50 year perspective. Evanston, IL: The American Board of Thoracic Surgery; 1998. 3. The American Board of Thoracic Surgery. Certification-5 year exam pass/fail rate. Available at https://www.abts.org/root/ home/certification.aspx. 4. Moffatt-Bruce SD, Ross P, Williams TE Jr. American Board of Thoracic Surgery examination: fewer graduates, more failures. J Thorac Cardiovasc Surg 2014;147:1464–9. 5. Shemin R, Ikonomidis JS. Thoracic Surgery Workforce: report of STS/AATS Thoracic Surgery Practice and Access Task Force—snapshot 2010. Ann Thorac Surg 2012;93:348–55. 6. Accreditation Council for Graduate Medical Education (ACGME) - Public List of ACGME Accredited Programs and Sponsoring Institutions. Available at https://www.acgme.org/ ads/public. 7. American Board of Thoracic Surgery. Maintenance of certification. Available at https://www.abts.org/root/home/ maintenance-of-certification.aspx.
