CHAPTER 7
Education Above and Beyond: Innovative STS Educational Initiatives Sidney Levitsky, MD, W. Randolph Chitwood, MD, Mark B. Orringer, MD, and Michael J. Mack, MD Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Department of Cardiovascular Sciences, East Carolina University, Greenville, North Carolina; Section of Thoracic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan; and Cardiothoracic Surgery, Baylor Health Care System, Plano, Texas
E
ducation has always been a driving force for The Society of Thoracic Surgeons (STS), and when one thinks of STS education, it may be the flagship Annual Meeting that initially comes to mind. This chapter focuses on specific educational activities, outside of core Annual Meeting sessions, that STS introduced based on its objective “to promote the professional and educational development of those surgeons specializing in the field of thoracic surgery.” The history of the STS Annual Meeting (see Chapter 3) highlights seminal presentations and groundbreaking research that have had important implications for the practice of cardiothoracic surgery. But STS education is far broader than just the Annual Meeting. Surgeon leaders, supported by the STS staff, strive tirelessly to find new, innovative, and meaningful educational activities that continue the STS tradition of helping cardiothoracic surgeons serve patients better.
Tech-Con: Spawning Innovation and Technology The STS/American Association for Thoracic Surgery (AATS) Tech-Con program developed from a need to revitalize cardiothoracic surgery for the 21st century and spur education and interest in new innovations and technology for the specialty. Before 2000, interventional cardiac therapy was changing rapidly. Many senior surgeons failed to embrace the coming changes toward less invasive cardiac and thoracic surgery. Nevertheless, a few surgeons recognized the need for a technologic renaissance in the specialty. The Cardiothoracic Technology and Techniques meeting and the New Era Cardiac Care meeting were initiated in 1996 and 1997, respectively, to spawn development of new ideas, innovative devices, and effective least-invasive operations. About the same time, a seminal meeting, “Recent Advances in Minimally Invasive Cardiac Surgery (1997),” was held at the University of Hannover in Germany. This novel meeting paved the way for the first meeting of “Pioneering Techniques in Cardiac Surgery (1999)” in Leipzig, Germany, with both conferences transmitting live new cardiac operations to
Address correspondence to Dr Levitsky, Beth Israel Deaconess Medical Center, Division of Cardiothoracic Surgery, 110 Francis St, Ste 2A, Boston, MA 02215; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
interested audiences. Thus, these “boutique” meetings also began to address the need for the development and application of new technologies in cardiac surgery. As an additional impetus to change, Dr Cosgrove challenged surgeons in his 2000 AATS Presidential Address, “Let it be said of the first year of a new millennium, this was the time when thoracic surgeons recognized the imperative for innovation in clinical practice, in research, in education, and in health care delivery” [1]. Most cardiothoracic operations were based on traditional, proven techniques with good outcomes, and most senior surgeons were averse to making innovative changes. Other venues besides the STS Annual Meeting became more attractive and useful for young surgeons to learn new principles. Nevertheless, under the leadership of STS President Mark B. Orringer, MD, and AATS President Timothy J. Gardner, MD, STS and AATS recognized the need to become more involved in embracing the use of new devices and techniques. W. Randolph “Ranny” Chitwood, MD (Fig 1), and Dr Michael J. Mack, MD (Fig 2), assembled a group of STS and AATS members to address the challenge of developing appropriate programs and educating members in new technology. STS/AATS Tech-Con emerged from that collaboration, and the name “Tech-Con” was coined by Dr Chitwood to reflect the new and cutting-edge content of the meeting. Subsequently the European Association for Cardio-Thoracic Surgery developed “Techno College” to reflect the same paradigm shift in education. Originally, Tech-Con was intended to alternate between the STS and AATS Annual Meetings; however, it was decided collectively that Tech-Con should be sponsored by both organizations but remain immediately before the STS Annual Meeting. At the same time, the AATS postgraduate meeting would now be deemed a joint STS/ AATS activity and remain part of the AATS Annual Meeting. The first STS/AATS Tech-Con was held in January 2002 before the STS 38th Annual Meeting in Fort Lauderdale, Florida. The intent was to introduce cardiothoracic surgeons to new technology and techniques. Topics at TechCon 2002 included coronary artery graft connectors, off-pump coronary surgery, robotics, new treatments for atrial fibrillation, new imaging modalities for lung surgery, gene therapy, tissue engineering, ventricular reconstruction, and pulmonary navigational surgery. In addition, there was a session on breakthrough technologies. Ann Thorac Surg 2014;97:S29–S33 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.006
S30
STS 50TH ANNIVERSARY LEVITSKY ET AL STS EDUCATIONAL INITIATIVES
Ann Thorac Surg 2014;97:S29–S33
STS University: Hands-On Learning
Fig 1. W. Randolph Chitwood, Jr, MD.
Tech-Con has been a remarkable success, with more than 1,000 attendees at most meetings. It has become the standard “watering hole” for both young and experienced surgeons to learn about evolving devices and surgical procedures and how to apply these methods safely. Over the years, the program has expanded and embraced new technology used in both general thoracic surgery and cardiac surgery. Clearly, Tech-Con has benefited both surgeons and patients. It has helped introduce surgeons to catheterbased imaging and endoscopic and minimally invasive skills. Transcutaneous valve operations now are in the scope of practice. New ventricular assist devices have emerged and are now standard therapy for advanced heart failure. Robotic technology is on the cusp of wider application in thoracic and cardiac surgery. Minimally invasive valve surgery has become a standard. Off-pump coronary surgery has been perfected, and even hybrid coronary operations that use both arterial conduit and stents together. All of this technology was either introduced or more widely disseminated at Tech-Con. Tech-Con will offer its 13th program at the STS 50th Annual Meeting in Orlando in January 2014. No doubt, the wisdom of the professional societies has prevailed in providing this venue that has helped move cardiothoracic surgeons into a more advanced technologic surgical mode. Clearly, as STS begins the second half of its centenary, innovative surgeons will keep the specialty at the forefront of technology development and application. Cardiothoracic surgeons will be able to help more patients effectively with the best modalities. It was Tech-Con that helped spawn the revolution that enticed cardiothoracic surgeons to move from “moldy” to “molding the future” of optimal patient care.
The origins of the STS University (STS U) date back to the January 2004 Presidential address in which Robert A. Guyton, MD, challenged the membership to innovate: “Innovation, for us, is survival. . . . If we are not the creators and the owners of innovation, then we will be the victims of innovation” [2]. A few months later, Richard H. Feins, MD (Fig 3), Chair of the Workforce on Annual Meeting, Dr Mack, Chair of the Tech-Con Task Force, and Damon K. Marquis, MA, MS, STS Director of Education and Member Services, met in a cafeteria at the AATS Annual Meeting to discuss and plan the following year’s STS Annual Meeting. Together, they noted that all previous meeting activities had consisted of didactic presentations and came up with an idea to develop an educational module consisting of hands-on practical experience outside of the operating room. The decision to hold these new hand-on courses on Wednesday morning of the Annual Meeting was easy—during the previous few years, meeting attendance had markedly decreased on Wednesday mornings, providing an opportunity to generate excitement and attendance on the last day of the meeting. Thus, STS U was born. On the back of a napkin, 11 courses with topics and suggested course directors were sketched out. Marquis and staff were tasked with organizing STS U. At that time, the Accreditation Council for Continuing Medical Education (ACCME) could provide neither guidance nor approval for this new educational model of teaching practical technical procedures at an academic, lecture-based meeting. Later, the STS U model for developing and implementing procedural education helped to set ACCME standards for developing hands-on procedural education.
Fig 2. Michael J. Mack, MD.
Ann Thorac Surg 2014;97:S29–S33
Fig 3. Richard H. Feins, MD.
STS U was initiated at the Society’s 41st Annual Meeting in Tampa on January 26, 2005. The program was divided by subspecialty, and each subspecialty course included a didactic portion, a wet lab, and a video demonstration or transmission of a live surgical procedure. The congenital heart surgery portion of the inaugural STS U consisted of a single course, “Surgery to Reconstruct the RV Outflow Tract” with John W. Brown, MD, and Charles D. Fraser, MD, as course directors. The general thoracic surgery portion consisted of three courses: “The Role of Esophageal Ultrasound in the Evaluation of Mediastinal Disease,” led by Robert J. Cerfolio, MD, and Mohamed A. Eloubeidi, MD; “Thoracoscopic Sympathectomy,” led by Daniel L. Miller, MD, and Todd Dewey, MD; and “Lung Volume Reduction Surgery (LVRS),” led by Malcolm M. DeCamp, MD, and Francis C. Noble, MD. The adult cardiac surgery portion consisted of four courses: “Intraoperative Echocardiography,” led by Robert Savage, MD, A. Marc Gillinov, MD, and Delos Cosgrove, MD; “Introduction to Catheter-Based Techniques 101,” led by David E. Allie, MD; “Endovascular Stenting for Descending Aortic Aneurysms,” led by Nicholas T. Kouchoukos, MD; and “Adult Valve Surgery,” led by Joseph E. Bavaria, MD, and Delos Cosgrove, MD. Industry collaborators donated instruments and devices. Although industry representatives were allowed in the classrooms, the number was strictly limited; all representatives had clearly marked identification badges and were required to wear special colored gowns. Moreover, industry representatives were prohibited from teaching or marketing. Industry was extremely supportive of these rules. Attendees did not pay additional fees for the initial courses; however, to help prevent “no-shows,” a nominal charge was instituted beginning in 2006.
STS 50TH ANNIVERSARY LEVITSKY ET AL STS EDUCATIONAL INITIATIVES
S31
In its early years, STS U included live operations; however, STS U discontinued live surgical presentations beginning with the 2008 Annual Meeting. A few months later, at the request of the Standards and Ethics Committee chaired by Robert M. Sade, MD, the STS Board of Directors adopted a policy prohibiting broadcast of live operations at STS Annual Meetings and also provided guidelines for members regarding participation in the broadcast of live operations at other large meetings. Despite the change in course content, no effect was noted on attendance at STS U courses. Annual attendance has varied from 500 to 1,000 attendees, depending on the number of courses offered. Over the years, hands-on time increased and the didactic lecture time decreased. In 2014, the didactic element of STS U will be eliminated completely and will be replaced by an online video segment that will be offered in advance of the meeting. STS University has matured into one of the strongest and most popular educational activities at the STS Annual Meeting. It was also the inspiration for the CT Surgery in the Future program, developed in 2008. This annual single-evening educational event for medical students and general surgery residents is an introduction and an encouragement to consider the specialty of cardiothoracic surgery. The program is offered during the American College of Surgeons Clinical Congress and has generated genuine enthusiasm among attendees and likely encouraged many future cardiothoracic surgeons.
STS Clinical Practice Guidelines and Patient Safety Initiatives With the adoption of new STS Bylaws and a new governance structure at the 2002 Annual Meeting, the traditional committee structure of the Society was replaced by Councils and associated Workforces, designed to provide a more “nimble,” action-oriented framework. The 2002–2003 STS organizational structure included the Council on Quality Assurance and Patient Advocacy, chaired by T. Bruce Ferguson, MD. Within this Council, the Workforce on Clinical Pathways, chaired by Fred H. Edwards, MD, and the Workforce on Patient Advocacy, Communications and Patient Safety, chaired by Thoralf M. Sundt, MD, became the formal source of STS efforts to develop two new avenues for education: clinical practice guidelines and patient safety initiatives.
Clinical Practice Guidelines The election of Frederick L. Grover, MD, to the office of STS Second Vice President at the 2004 STS Annual Meeting set off a chain reaction within the Society’s governance structure. The following month, the STS Executive Committee installed Dr Edwards to replace Dr Grover as Chair of the Workforce on National Databases and appointed Charles R. Bridges, MD, SD, to replace Dr Edwards as Chair of the Workforce on Evidence Based Surgery. John D. Mitchell, MD, succeeded Dr Bridges in 2010.
S32
STS 50TH ANNIVERSARY LEVITSKY ET AL STS EDUCATIONAL INITIATIVES
It is through the Workforce on Evidence Based Surgery that STS Clinical Practice Guidelines are developed and updated. The process has evolved over the years, and in June 2013, the STS Executive Committee approved an updated procedure for writing guidelines that follows very rigorous standards outlined in the American College of Cardiology/American Hospital Association Guideline Methodology Manual, the Council of Medical Specialty Societies Principles for the Development of Specialty Society Clinical Practice Guideline, and the Institute of Medicine (IOM) consensus report, “Clinical Practice Guidelines We Can Trust.” At that same time, the Executive Committee approved policy related to the development of clinical practice guidelines with other organizations. Final guideline documents are sent to The Annals of Thoracic Surgery for publication and are available at no charge on www.sts.org/guidelines. Currently, 17 STS Clinical Practice Guidelines are available and more are in the pipeline. STS Clinical Practice Guidelines are among the most popular resources the Society offers, available online, in print, and through Skyscape (www.skyscape.com) for personal digital assistants (PDAs). The first three PDAcompatible guidelines became available in December 2009. They are Blood Glucose, Antibiotic Prophylaxis, and Management of Barrett’s Esophagus with High-Grade Dysplasia. Through June 2013, each of the guidelines had been downloaded from Skyscape in excess of 408,000 times. A fourth guideline, Blood Conversation, became available on Skyscape in March 2009 and has been downloaded more than 321,000 times.
Patient Safety Initiatives In November 1999, the IOM released its report, “To Err is Human: Building a Safer Health System,” which highlighted studies indicating that medical errors are responsible for possibly as many as 98,000 patient deaths each year in United States [3]. In 2001, responding to the IOM recommendation for the creation of a National Center for Patient Safety, the United States Congress allocated $50 million annually for patient safety research to the Agency for Healthcare Research and Quality (AHRQ), the lead federal agency for health care safety. AHRQ functioned to (1) organize patient safety activities, (2) provide grants to other organizations, (3) serve as a clearing house for patient safety information, and (4) publish guidelines for evidence-based or “best practices.” Launch of the National Guideline Clearinghouse, an organization to which STS Clinical Practice Guidelines are routinely submitted for dissemination to audiences beyond the STS membership, was an AHRQ initiative. The Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery and its accompanying guidelines for implementation developed by The Joint Commission were endorsed by the STS Board of Directors in October 2003 upon the recommendation of the Quality Assurance and Patient Advocacy Council Operating Board. The next year, STS President
Ann Thorac Surg 2014;97:S29–S33
Peter C. Pairolero, MD, invited James P. Bagian, MD, PE, the first Director of the VA National Center for Patient Safety and a former astronaut, to deliver the Thomas B. Ferguson Lecture at the 2005 STS Annual Meeting. In addition, Town Hall meetings were planned to discuss the relevance of the patient safety movement to the practicing cardiothoracic surgeon, how the issue of hierarchy may contribute to errors, and the implications of current patient safety legislation and related liability issues. In a January 2005 editorial, “Focus on Patient Safety: Good News for the Practicing Surgeon” in The Annals of Thoracic Surgery, Dr Sundt and colleagues addressed such topics as flattening hierarchy, near misses and adverse events, how to learn from error, and getting away from blame and shame [4]. These patient safety initiatives from the Workforce on Patient Advocacy, Communications, and Patient Safety were inextricably linked to those from the Workforce on Evidence Based Surgery. By October 2005, the Practice Education Task Force, chaired by M. Blair Marshall, MD, was developing a patient safety program for presentation at the 2006 STS Annual Meeting. Simultaneously, the Patient Safety Data Task Force, chaired by Dr Sundt, was beginning a process to include patient safety data in the STS National Database (see Chapter 11). In 2008, the Society adopted a Declaration on Tobacco Control. The following year, the Society released operating room checklists for the three major cardiothoracic surgical subspecialties, aimed at decreasing cardiothoracic surgical errors. These initiatives were recognized by nationally prominent surgeon–author Atul Gawande, MD, during his Ferguson Lecture at the 2011 Annual Meeting. Available since the fall of 2009, these checklists are also a popular STS resource.
Standalone Education Courses During the course of the past decade, the Society has spread its educational wings beyond the Annual Meeting to provide its members with enhanced learning opportunities online and through standalone courses. Development of the 2005 STS Endovascular Surgery Training Course serves as a paradigm, illustrating the speed in which the Society has proven itself able to respond to the educational needs of members facing rapidly changing disruptive technologies. In August 2004, Sidney Levitsky, MD, received information that a company was considering developing an endovascular device for aortic root replacement. During an STS leadership meeting that fall, Dr Levitsky, then STS First Vice President, expressed concern regarding this potentially disruptive technological advance and suggested that the Society develop an educational program to address it. STS President Peter C. Pairolero, MD, agreed and appointed Dr Levitsky to direct the process. Nicholas T. Kouchoukos, MD, was appointed Chair of the Endovascular Surgery Task Force, which met on an urgent basis on November 7, 2004, in New Orleans. They decided that STS should develop educational programs
Ann Thorac Surg 2014;97:S29–S33
and guidelines for credentialing cardiothoracic surgeons to perform endovascular procedures. An introductory educational course was arranged for the 2005 STS Annual Meeting as a part of the STS University. A second meeting of the Task Force was held on January 25, 2005, in conjunction with representatives from the biomedical device industry, including Medtronic Inc, W. L. Gore & Associates Inc, and Cook Medical Inc. Ultimately, a position paper on the credentialing of cardiothoracic surgeons to perform endovascular procedures was prepared and subsequently published in partnership with AATS in The Annals [5]. On August 26 and 27, 2005, the first standalone STS Endovascular Course was held in Rosemont, Illinois, directed by Dr Bavaria and Grayson H. Wheatley, MD. Marquis worked with the Task Force to help ensure that the course complied with ACCME Essentials, Standards, and Policies. Required attendance at a course like the STS Endovascular Course later became part of the credentialing guidelines. The intensive 2-day educational course was “sold out” within weeks of the announcement, demonstrating the importance of this educational offering. The process of developing an educational course associated with guidelines and credentialing became the
STS 50TH ANNIVERSARY LEVITSKY ET AL STS EDUCATIONAL INITIATIVES
S33
STS template for educating its members to manage future disruptive technologies such as ventricular assist devices and, more recently, transcatheter aortic valve replacement devices. STS initiatives related to education, patient safety, and development of evidence-based practice guidelines have grown dramatically, particularly in the past decade. All are linked by the common goal of improving the care of cardiothoracic surgery patients.
References 1. Cosgrove DM. The innovation imperative. J Thorac Cardiovasc Surg 2000;120:839–42. 2. Guyton RA. Quo vadimus? Ann Thorac Surg 2004;78:391–8. 3. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999. 4. Sundt TM, Brown JP, Uhlig PNSTS Workforce on Patient Advocacy, Communications, and Safety. Focus on patient safety: good news for the practicing surgeon. Ann Thorac Surg 2005;79:11–5. 5. Kouchoukos NT, Bavaria JE, Coselli JS, et al. Guidelines for credentialing of practitioners to perform endovascular stentgrafting of the thoracic aorta. Ann Thorac Surg 2006;81: 1174–6.
Education Above and Beyond: Innovative STS Educational Initiatives Sidney Levitsky, MD, W. Randolph Chitwood, MD, Mark B. Orringer, MD, and Michael J. Mack, MD Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Department of Cardiovascular Sciences, East Carolina University, Greenville, North Carolina; Section of Thoracic Surgery, University of Michigan Medical Center, Ann Arbor, Michigan; and Cardiothoracic Surgery, Baylor Health Care System, Plano, Texas
E
ducation has always been a driving force for The Society of Thoracic Surgeons (STS), and when one thinks of STS education, it may be the flagship Annual Meeting that initially comes to mind. This chapter focuses on specific educational activities, outside of core Annual Meeting sessions, that STS introduced based on its objective “to promote the professional and educational development of those surgeons specializing in the field of thoracic surgery.” The history of the STS Annual Meeting (see Chapter 3) highlights seminal presentations and groundbreaking research that have had important implications for the practice of cardiothoracic surgery. But STS education is far broader than just the Annual Meeting. Surgeon leaders, supported by the STS staff, strive tirelessly to find new, innovative, and meaningful educational activities that continue the STS tradition of helping cardiothoracic surgeons serve patients better.
Tech-Con: Spawning Innovation and Technology The STS/American Association for Thoracic Surgery (AATS) Tech-Con program developed from a need to revitalize cardiothoracic surgery for the 21st century and spur education and interest in new innovations and technology for the specialty. Before 2000, interventional cardiac therapy was changing rapidly. Many senior surgeons failed to embrace the coming changes toward less invasive cardiac and thoracic surgery. Nevertheless, a few surgeons recognized the need for a technologic renaissance in the specialty. The Cardiothoracic Technology and Techniques meeting and the New Era Cardiac Care meeting were initiated in 1996 and 1997, respectively, to spawn development of new ideas, innovative devices, and effective least-invasive operations. About the same time, a seminal meeting, “Recent Advances in Minimally Invasive Cardiac Surgery (1997),” was held at the University of Hannover in Germany. This novel meeting paved the way for the first meeting of “Pioneering Techniques in Cardiac Surgery (1999)” in Leipzig, Germany, with both conferences transmitting live new cardiac operations to
Address correspondence to Dr Levitsky, Beth Israel Deaconess Medical Center, Division of Cardiothoracic Surgery, 110 Francis St, Ste 2A, Boston, MA 02215; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
interested audiences. Thus, these “boutique” meetings also began to address the need for the development and application of new technologies in cardiac surgery. As an additional impetus to change, Dr Cosgrove challenged surgeons in his 2000 AATS Presidential Address, “Let it be said of the first year of a new millennium, this was the time when thoracic surgeons recognized the imperative for innovation in clinical practice, in research, in education, and in health care delivery” [1]. Most cardiothoracic operations were based on traditional, proven techniques with good outcomes, and most senior surgeons were averse to making innovative changes. Other venues besides the STS Annual Meeting became more attractive and useful for young surgeons to learn new principles. Nevertheless, under the leadership of STS President Mark B. Orringer, MD, and AATS President Timothy J. Gardner, MD, STS and AATS recognized the need to become more involved in embracing the use of new devices and techniques. W. Randolph “Ranny” Chitwood, MD (Fig 1), and Dr Michael J. Mack, MD (Fig 2), assembled a group of STS and AATS members to address the challenge of developing appropriate programs and educating members in new technology. STS/AATS Tech-Con emerged from that collaboration, and the name “Tech-Con” was coined by Dr Chitwood to reflect the new and cutting-edge content of the meeting. Subsequently the European Association for Cardio-Thoracic Surgery developed “Techno College” to reflect the same paradigm shift in education. Originally, Tech-Con was intended to alternate between the STS and AATS Annual Meetings; however, it was decided collectively that Tech-Con should be sponsored by both organizations but remain immediately before the STS Annual Meeting. At the same time, the AATS postgraduate meeting would now be deemed a joint STS/ AATS activity and remain part of the AATS Annual Meeting. The first STS/AATS Tech-Con was held in January 2002 before the STS 38th Annual Meeting in Fort Lauderdale, Florida. The intent was to introduce cardiothoracic surgeons to new technology and techniques. Topics at TechCon 2002 included coronary artery graft connectors, off-pump coronary surgery, robotics, new treatments for atrial fibrillation, new imaging modalities for lung surgery, gene therapy, tissue engineering, ventricular reconstruction, and pulmonary navigational surgery. In addition, there was a session on breakthrough technologies. Ann Thorac Surg 2014;97:S29–S33 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.006
S30
STS 50TH ANNIVERSARY LEVITSKY ET AL STS EDUCATIONAL INITIATIVES
Ann Thorac Surg 2014;97:S29–S33
STS University: Hands-On Learning
Fig 1. W. Randolph Chitwood, Jr, MD.
Tech-Con has been a remarkable success, with more than 1,000 attendees at most meetings. It has become the standard “watering hole” for both young and experienced surgeons to learn about evolving devices and surgical procedures and how to apply these methods safely. Over the years, the program has expanded and embraced new technology used in both general thoracic surgery and cardiac surgery. Clearly, Tech-Con has benefited both surgeons and patients. It has helped introduce surgeons to catheterbased imaging and endoscopic and minimally invasive skills. Transcutaneous valve operations now are in the scope of practice. New ventricular assist devices have emerged and are now standard therapy for advanced heart failure. Robotic technology is on the cusp of wider application in thoracic and cardiac surgery. Minimally invasive valve surgery has become a standard. Off-pump coronary surgery has been perfected, and even hybrid coronary operations that use both arterial conduit and stents together. All of this technology was either introduced or more widely disseminated at Tech-Con. Tech-Con will offer its 13th program at the STS 50th Annual Meeting in Orlando in January 2014. No doubt, the wisdom of the professional societies has prevailed in providing this venue that has helped move cardiothoracic surgeons into a more advanced technologic surgical mode. Clearly, as STS begins the second half of its centenary, innovative surgeons will keep the specialty at the forefront of technology development and application. Cardiothoracic surgeons will be able to help more patients effectively with the best modalities. It was Tech-Con that helped spawn the revolution that enticed cardiothoracic surgeons to move from “moldy” to “molding the future” of optimal patient care.
The origins of the STS University (STS U) date back to the January 2004 Presidential address in which Robert A. Guyton, MD, challenged the membership to innovate: “Innovation, for us, is survival. . . . If we are not the creators and the owners of innovation, then we will be the victims of innovation” [2]. A few months later, Richard H. Feins, MD (Fig 3), Chair of the Workforce on Annual Meeting, Dr Mack, Chair of the Tech-Con Task Force, and Damon K. Marquis, MA, MS, STS Director of Education and Member Services, met in a cafeteria at the AATS Annual Meeting to discuss and plan the following year’s STS Annual Meeting. Together, they noted that all previous meeting activities had consisted of didactic presentations and came up with an idea to develop an educational module consisting of hands-on practical experience outside of the operating room. The decision to hold these new hand-on courses on Wednesday morning of the Annual Meeting was easy—during the previous few years, meeting attendance had markedly decreased on Wednesday mornings, providing an opportunity to generate excitement and attendance on the last day of the meeting. Thus, STS U was born. On the back of a napkin, 11 courses with topics and suggested course directors were sketched out. Marquis and staff were tasked with organizing STS U. At that time, the Accreditation Council for Continuing Medical Education (ACCME) could provide neither guidance nor approval for this new educational model of teaching practical technical procedures at an academic, lecture-based meeting. Later, the STS U model for developing and implementing procedural education helped to set ACCME standards for developing hands-on procedural education.
Fig 2. Michael J. Mack, MD.
Ann Thorac Surg 2014;97:S29–S33
Fig 3. Richard H. Feins, MD.
STS U was initiated at the Society’s 41st Annual Meeting in Tampa on January 26, 2005. The program was divided by subspecialty, and each subspecialty course included a didactic portion, a wet lab, and a video demonstration or transmission of a live surgical procedure. The congenital heart surgery portion of the inaugural STS U consisted of a single course, “Surgery to Reconstruct the RV Outflow Tract” with John W. Brown, MD, and Charles D. Fraser, MD, as course directors. The general thoracic surgery portion consisted of three courses: “The Role of Esophageal Ultrasound in the Evaluation of Mediastinal Disease,” led by Robert J. Cerfolio, MD, and Mohamed A. Eloubeidi, MD; “Thoracoscopic Sympathectomy,” led by Daniel L. Miller, MD, and Todd Dewey, MD; and “Lung Volume Reduction Surgery (LVRS),” led by Malcolm M. DeCamp, MD, and Francis C. Noble, MD. The adult cardiac surgery portion consisted of four courses: “Intraoperative Echocardiography,” led by Robert Savage, MD, A. Marc Gillinov, MD, and Delos Cosgrove, MD; “Introduction to Catheter-Based Techniques 101,” led by David E. Allie, MD; “Endovascular Stenting for Descending Aortic Aneurysms,” led by Nicholas T. Kouchoukos, MD; and “Adult Valve Surgery,” led by Joseph E. Bavaria, MD, and Delos Cosgrove, MD. Industry collaborators donated instruments and devices. Although industry representatives were allowed in the classrooms, the number was strictly limited; all representatives had clearly marked identification badges and were required to wear special colored gowns. Moreover, industry representatives were prohibited from teaching or marketing. Industry was extremely supportive of these rules. Attendees did not pay additional fees for the initial courses; however, to help prevent “no-shows,” a nominal charge was instituted beginning in 2006.
STS 50TH ANNIVERSARY LEVITSKY ET AL STS EDUCATIONAL INITIATIVES
S31
In its early years, STS U included live operations; however, STS U discontinued live surgical presentations beginning with the 2008 Annual Meeting. A few months later, at the request of the Standards and Ethics Committee chaired by Robert M. Sade, MD, the STS Board of Directors adopted a policy prohibiting broadcast of live operations at STS Annual Meetings and also provided guidelines for members regarding participation in the broadcast of live operations at other large meetings. Despite the change in course content, no effect was noted on attendance at STS U courses. Annual attendance has varied from 500 to 1,000 attendees, depending on the number of courses offered. Over the years, hands-on time increased and the didactic lecture time decreased. In 2014, the didactic element of STS U will be eliminated completely and will be replaced by an online video segment that will be offered in advance of the meeting. STS University has matured into one of the strongest and most popular educational activities at the STS Annual Meeting. It was also the inspiration for the CT Surgery in the Future program, developed in 2008. This annual single-evening educational event for medical students and general surgery residents is an introduction and an encouragement to consider the specialty of cardiothoracic surgery. The program is offered during the American College of Surgeons Clinical Congress and has generated genuine enthusiasm among attendees and likely encouraged many future cardiothoracic surgeons.
STS Clinical Practice Guidelines and Patient Safety Initiatives With the adoption of new STS Bylaws and a new governance structure at the 2002 Annual Meeting, the traditional committee structure of the Society was replaced by Councils and associated Workforces, designed to provide a more “nimble,” action-oriented framework. The 2002–2003 STS organizational structure included the Council on Quality Assurance and Patient Advocacy, chaired by T. Bruce Ferguson, MD. Within this Council, the Workforce on Clinical Pathways, chaired by Fred H. Edwards, MD, and the Workforce on Patient Advocacy, Communications and Patient Safety, chaired by Thoralf M. Sundt, MD, became the formal source of STS efforts to develop two new avenues for education: clinical practice guidelines and patient safety initiatives.
Clinical Practice Guidelines The election of Frederick L. Grover, MD, to the office of STS Second Vice President at the 2004 STS Annual Meeting set off a chain reaction within the Society’s governance structure. The following month, the STS Executive Committee installed Dr Edwards to replace Dr Grover as Chair of the Workforce on National Databases and appointed Charles R. Bridges, MD, SD, to replace Dr Edwards as Chair of the Workforce on Evidence Based Surgery. John D. Mitchell, MD, succeeded Dr Bridges in 2010.
S32
STS 50TH ANNIVERSARY LEVITSKY ET AL STS EDUCATIONAL INITIATIVES
It is through the Workforce on Evidence Based Surgery that STS Clinical Practice Guidelines are developed and updated. The process has evolved over the years, and in June 2013, the STS Executive Committee approved an updated procedure for writing guidelines that follows very rigorous standards outlined in the American College of Cardiology/American Hospital Association Guideline Methodology Manual, the Council of Medical Specialty Societies Principles for the Development of Specialty Society Clinical Practice Guideline, and the Institute of Medicine (IOM) consensus report, “Clinical Practice Guidelines We Can Trust.” At that same time, the Executive Committee approved policy related to the development of clinical practice guidelines with other organizations. Final guideline documents are sent to The Annals of Thoracic Surgery for publication and are available at no charge on www.sts.org/guidelines. Currently, 17 STS Clinical Practice Guidelines are available and more are in the pipeline. STS Clinical Practice Guidelines are among the most popular resources the Society offers, available online, in print, and through Skyscape (www.skyscape.com) for personal digital assistants (PDAs). The first three PDAcompatible guidelines became available in December 2009. They are Blood Glucose, Antibiotic Prophylaxis, and Management of Barrett’s Esophagus with High-Grade Dysplasia. Through June 2013, each of the guidelines had been downloaded from Skyscape in excess of 408,000 times. A fourth guideline, Blood Conversation, became available on Skyscape in March 2009 and has been downloaded more than 321,000 times.
Patient Safety Initiatives In November 1999, the IOM released its report, “To Err is Human: Building a Safer Health System,” which highlighted studies indicating that medical errors are responsible for possibly as many as 98,000 patient deaths each year in United States [3]. In 2001, responding to the IOM recommendation for the creation of a National Center for Patient Safety, the United States Congress allocated $50 million annually for patient safety research to the Agency for Healthcare Research and Quality (AHRQ), the lead federal agency for health care safety. AHRQ functioned to (1) organize patient safety activities, (2) provide grants to other organizations, (3) serve as a clearing house for patient safety information, and (4) publish guidelines for evidence-based or “best practices.” Launch of the National Guideline Clearinghouse, an organization to which STS Clinical Practice Guidelines are routinely submitted for dissemination to audiences beyond the STS membership, was an AHRQ initiative. The Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery and its accompanying guidelines for implementation developed by The Joint Commission were endorsed by the STS Board of Directors in October 2003 upon the recommendation of the Quality Assurance and Patient Advocacy Council Operating Board. The next year, STS President
Ann Thorac Surg 2014;97:S29–S33
Peter C. Pairolero, MD, invited James P. Bagian, MD, PE, the first Director of the VA National Center for Patient Safety and a former astronaut, to deliver the Thomas B. Ferguson Lecture at the 2005 STS Annual Meeting. In addition, Town Hall meetings were planned to discuss the relevance of the patient safety movement to the practicing cardiothoracic surgeon, how the issue of hierarchy may contribute to errors, and the implications of current patient safety legislation and related liability issues. In a January 2005 editorial, “Focus on Patient Safety: Good News for the Practicing Surgeon” in The Annals of Thoracic Surgery, Dr Sundt and colleagues addressed such topics as flattening hierarchy, near misses and adverse events, how to learn from error, and getting away from blame and shame [4]. These patient safety initiatives from the Workforce on Patient Advocacy, Communications, and Patient Safety were inextricably linked to those from the Workforce on Evidence Based Surgery. By October 2005, the Practice Education Task Force, chaired by M. Blair Marshall, MD, was developing a patient safety program for presentation at the 2006 STS Annual Meeting. Simultaneously, the Patient Safety Data Task Force, chaired by Dr Sundt, was beginning a process to include patient safety data in the STS National Database (see Chapter 11). In 2008, the Society adopted a Declaration on Tobacco Control. The following year, the Society released operating room checklists for the three major cardiothoracic surgical subspecialties, aimed at decreasing cardiothoracic surgical errors. These initiatives were recognized by nationally prominent surgeon–author Atul Gawande, MD, during his Ferguson Lecture at the 2011 Annual Meeting. Available since the fall of 2009, these checklists are also a popular STS resource.
Standalone Education Courses During the course of the past decade, the Society has spread its educational wings beyond the Annual Meeting to provide its members with enhanced learning opportunities online and through standalone courses. Development of the 2005 STS Endovascular Surgery Training Course serves as a paradigm, illustrating the speed in which the Society has proven itself able to respond to the educational needs of members facing rapidly changing disruptive technologies. In August 2004, Sidney Levitsky, MD, received information that a company was considering developing an endovascular device for aortic root replacement. During an STS leadership meeting that fall, Dr Levitsky, then STS First Vice President, expressed concern regarding this potentially disruptive technological advance and suggested that the Society develop an educational program to address it. STS President Peter C. Pairolero, MD, agreed and appointed Dr Levitsky to direct the process. Nicholas T. Kouchoukos, MD, was appointed Chair of the Endovascular Surgery Task Force, which met on an urgent basis on November 7, 2004, in New Orleans. They decided that STS should develop educational programs
Ann Thorac Surg 2014;97:S29–S33
and guidelines for credentialing cardiothoracic surgeons to perform endovascular procedures. An introductory educational course was arranged for the 2005 STS Annual Meeting as a part of the STS University. A second meeting of the Task Force was held on January 25, 2005, in conjunction with representatives from the biomedical device industry, including Medtronic Inc, W. L. Gore & Associates Inc, and Cook Medical Inc. Ultimately, a position paper on the credentialing of cardiothoracic surgeons to perform endovascular procedures was prepared and subsequently published in partnership with AATS in The Annals [5]. On August 26 and 27, 2005, the first standalone STS Endovascular Course was held in Rosemont, Illinois, directed by Dr Bavaria and Grayson H. Wheatley, MD. Marquis worked with the Task Force to help ensure that the course complied with ACCME Essentials, Standards, and Policies. Required attendance at a course like the STS Endovascular Course later became part of the credentialing guidelines. The intensive 2-day educational course was “sold out” within weeks of the announcement, demonstrating the importance of this educational offering. The process of developing an educational course associated with guidelines and credentialing became the
STS 50TH ANNIVERSARY LEVITSKY ET AL STS EDUCATIONAL INITIATIVES
S33
STS template for educating its members to manage future disruptive technologies such as ventricular assist devices and, more recently, transcatheter aortic valve replacement devices. STS initiatives related to education, patient safety, and development of evidence-based practice guidelines have grown dramatically, particularly in the past decade. All are linked by the common goal of improving the care of cardiothoracic surgery patients.
References 1. Cosgrove DM. The innovation imperative. J Thorac Cardiovasc Surg 2000;120:839–42. 2. Guyton RA. Quo vadimus? Ann Thorac Surg 2004;78:391–8. 3. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999. 4. Sundt TM, Brown JP, Uhlig PNSTS Workforce on Patient Advocacy, Communications, and Safety. Focus on patient safety: good news for the practicing surgeon. Ann Thorac Surg 2005;79:11–5. 5. Kouchoukos NT, Bavaria JE, Coselli JS, et al. Guidelines for credentialing of practitioners to perform endovascular stentgrafting of the thoracic aorta. Ann Thorac Surg 2006;81: 1174–6.
