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  1. 1. Surgical education in changing times John R Benfield Eur J Cardiothorac Surg 1999;16:6-10 This information is current as of December 6, 2010 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://ejcts.ctsnetjournals.org/cgi/content/full/16/suppl_1/S6The European Journal of Cardio-thoracic Surgery is the official Journal of the European Associationfor Cardio-thoracic Surgery and the European Society of Thoracic Surgeons. Copyright © 1999 byEuropean Association for Cardio-Thoracic Surgery. Published by Elsevier. All rights reserved. PrintISSN: 1010-7940. Downloaded from ejcts.ctsnetjournals.org by on December 6, 2010
  2. 2. European Journal of Cardio-thoracic Surgery 16 (Suppl. 1) (1999) S6±S10 www.elsevier.com/locate/ejcts Surgical education in changing times q John R. Ben®eld 1 Division of Cardiothoracic Surgery, University of California, Davis Medical Center, Sacramento, CA 95817, USAKeywords: Education; Surgery1. Before thoracic surgery professorship that also included responsibility for anatomy and midwifery as well as surgery. Eventually, Philip Syng With due respect to Asia, Africa and other cultures Physick became the ®rst professor of surgery as a separatewherein there have undoubtedly been important happenings and distinct discipline.in surgical educations, I shall focus upon the United States New York, Boston and Baltimore were the centers ofand its European heritage. surgical excellence in the original 13 states; Chicago and The `art of surgery` was recognized at the time of Hippo- Rochester, Minnesota led the way in the Midwest. At Belle-crates [1,2]. In the beginning surgery was totally integrated vue Hospital, now the major clinical teaching center of Newinto medicine as a whole and it was taught by apprentice- York University, Stephen Smith in 1863 noted that the theo-ship, without curricula or standardization or formal evalua- retical schools of the ancients `¼do not teach practicaltion. Hundreds of years passed until surgical papers were medicine. They educate the brain, but leave the handsegregated into separate sections in scienti®c publications. palsied¼. Their graduates (are) like full ¯edged eagletsMeetings devoted exclusively to surgery did not emerge deprived of their wings [2].until about the 1890s. At the Massachusetts General Hospital, Henry Bigelow Europe was the cradle of knowledge and excellence in said `Clinical study is bed study. Here the student grapplessurgical education for Americans in the late 1800s until with the malady whose Protean forms he has as yet onlyapproximately the start of World War II. It has been esti- read¼ [2]. In short, the late 1800s in the United States sawmated that during the period from 1870 to 1914 there were a recognition of the need for practical experience in surgery.15 000 US undergraduate and postgraduate students in In the language of sports, surgery was recognized as a bodyGerman medical schools alone. There were also many contact sport.Americans studying in centers of excellence such as Vienna At the Johns Hopkins Hospital, Harvey Cushing, bestwhere the great Chicago surgeon Arthur D. Bevan noted that remembered for his fundamental contributions to neurolo-Billroth `¼taught surgery as a successful football coach gical surgery and whose greatest pride was in having sewnteaches his squad¼by training them in the actual work dura, conducted a course in animal surgery. He managed toitself[2]. carry this forward in large part because he defused the In the youngest days of America as a British colony, objections of anti-vivisectionists for whom he also servedmedical education was fragmented and sporadic. The ®rst as a veterinary surgeon. Cushing said the animal surgeryAmerican surgical textbook was a manual of military course `was by far the most satisfying and pro®table sourcesurgery in 1775. of contact between student and teacher I have ever experi- After the Declaration of Independence in 1776 there was enced¼. I believe it will make the future physician morelittle attention paid to medical education until formal medi- appreciate of the surgical viewpoint [2].The professor ofcal education began at the Medical College of Philadelphia surgery at John Hopkins University was William Stuartin 1865. At the start surgery was taught under the aegis of a Halstedt, a fascinating man who is often credited with having started the ®rst true residency in surgery. Under q Presented at the 2nd MITSIG International Symposium: Controversies Halstedt, the residency included no lectures or known curri-in Cardiothoracic Surgery, Hong Kong, November 20±21, 1998. culum. There were formal systematic sessions in Surgical E-mail address: jrbmd@worldnet.att.net (J.R. Ben®eld) Pathology. 1 Contact address: 11611 Terryhill Place, Los Angeles, CA 90049, USA. From the Mayo experience one learns more about theTel.: 11-310-889-9186; fax: 11-310-889-91961010-7940/99/$ - see front matter q 1999 Elsevier Science B.V. All rights reserved.PII: S10 10-7940(99)0017 3-6 Downloaded from ejcts.ctsnetjournals.org by on December 6, 2010
  3. 3. J.R. Ben®eld / European Journal of Cardio-thoracic Surgery 16 (Suppl. 1) (1999) S6±S10 S7evolution of surgical teaching in the 1800s. Will W. Mayo the seeds of postgraduate curricula in surgery emerged. Byin 1849 at the Indiana Medical College learned from the time Joseph Murray received the Nobel Prize for hislectures without clinical instruction. The young Will work in transplantation, there was an Accreditation CouncilMayo, in 1879 at the University of Michigan did have clin- for Graduate Medical Education in the US and each speci-ical instruction in surgery, but it was long distance education alty had a well de®ned structure for its residency programs.in amphitheater. By the time Charles Mayo attended the The system is not perfect, but it has become increasinglyRush Medical College in Chicago in 1885, he was able to de®ned. It is certainly better now than ever before insofar asobserve actual operations at close range. the average surgeon in residency is concerned. I am not sure Then came the Flexner Report of 1910 which called that the system offers the upper 10% of surgical residents theattention to the appalling level of medical education in the same opportunities as heretofore.US and Canada [3]. Flexner said that ` (The) pedagogicalvalue (of surgery) is¼ slight;¼ operations are performed inlarge amphitheaters¼. Most students see only the patients 2. Thoracic surgeryfeet and the surgeons head. It was clear that surgicaleducation, like the rest of medical education, needed a All specialties grew from the `Art of Medicine, andnew and different approach. general surgery is clearly the forerunner of thoracic surgery. In Chicago, my medical home town, the importance of I shall trace this differentiation process as I have done inthe surgical laboratory was championed by the great Chris- greater detail before [5]. Then I will comment about thetian Fenger who advised his students to `Beat a path from specialty as now practiced and governed and give you mythe operating room to the laboratory. Writing about Fenger, thoughts about the future.Hertzler said that his experience in surgical pathology had The earliest elective thoracic surgery was practicedbeen one of the most valuable lessons he had learned [4]. predominantly in the tuberculosis hospitals. Often the I had the privilege of being the last chief resident at the need for a service that did not exist initially pushed inter-University of Chicago in the Dallas B. Phemister tradition. nists and generalists into surgical adventures. By 1917 thePhemister allied surgery with basic science. Among his men who wished to focus upon thoracic surgery had comemost successful surgical faculty members was Lester R. together in the American Association for Thoracic Surgery.Dragstedt who had been recruited by Phemister from his Eleven years later, John Alexander, himself a victim ofposition as a physiology faculty member and sent to Europe tuberculosis. had started the ®rst residency in thoracicto learn surgery. I am not sure if it was Phemister or Drag- surgery at the University of Michigan. Two decades later,stedt who said that the laboratory must be `hatless distance in 1948, the Board of Thoracic Surgery was formed as anaway from the Operating Rooms. In any case, that is the way af®liate of the American Board of Surgery. Twenty threeit was. Dragstedt, the physiologist and originator of vagot- years thereafter, in 1971, the American Board of Thoracicomy as treatment for duodenal ulcer, conducted daily after- Surgery became independent of its general surgery parentnoon teas in his laboratory. This wonderfully civilized way board, although to this day each of the two boards has aof connecting the operating room with the research labora- liaison member from the other. In 1978, led by Hassantory persisted ever after `LRD succeeded Phemister as the Naja®, the directors of approved residencies in thoracicprofessor. The surgical amphitheater was replaced by 1:1 surgery came together as the Thoracic Surgery Directorsresident/faculty preceptorships of 6±12 month durations. Association. As cardiac surgery matured, there was muchEveryone served as a surgical pathology apprentice for at pressure to change the name of the American Board ofleast 6 months. A single resident each year was selected to Thoracic Surgery to re¯ect the importance of cardiacbecome chief resident and Instructor. When I had this privi- surgery [6]. A series of important, thought provoking, meet-lege I was already certi®ed by the American Board of ings to discuss education has taken place in the past 20Surgery. All but one of the Phemister tradition chief resi- years. These included a strategic planning meeting of thedents became full professors If I were pressed to select one Society of Thoracic Surgeons (STS) ± the largest group ofof the University of Chicago surgical products of the Phem- thoracic surgeons in the world [7]. The STS reaf®rmed theister era as the most prominent, I would choose Charles E. de®nition of thoracic surgery as a uni®ed specialty that nowHuggins who was awarded the Nobel prize for his work with includes three sub-specialties of cardiovascular: surgery forthe endocrine control of breast and prostate cancer. adults, general thoracic surgery and congenial heart surgery. The evolution of surgical education until now is illu- The Thoracic Surgery Directors Association, after a retreatstrated by looking back at surgical education during the the involved intense discussions the leaders of all approvedtime of three surgical Nobel Laureates. In the days of Theo- residencies, con®rmed that thoracic surgery would remain adore Kocher, awarded the Nobel Prize for his work with the uni®ed specialty with three recognized sub-specialties.thyroid, there was absolute professional authority. Young There was strong consensus that Thoracic Surgery Programsurgeons were anointed when they were judged to be Directors should become increasingly responsible for theready for independent work by their elders who were benign pre-requisite surgical education and signi®cant opinion indictators;. In the Huggins era of about 1945 to about 1970, favor of dropping certi®cation in general surgery as a prere- Downloaded from ejcts.ctsnetjournals.org by on December 6, 2010
  4. 4. S8 J.R. Ben®eld / European Journal of Cardio-thoracic Surgery 16 (Suppl. 1) (1999) S6±S10quisite in order to allow better and longer focus upon thor- quality of thoracic surgery and the quality of patient care inacic surgery. However, there was consensus that the pre- our specialty is being endangered worldwide by the fact thatrequisite of certi®cation in general surgery has served thor- incompletely educated surgeons are operating in the chestacic surgery well and that it should be kept [8]. [6]. I presented evidence to the effect that 60±80% of There is unanimity that excellence in clinical education is general thoracic surgery in Europe was being done byfundamental. Neither political or ®nancial considerations general surgeons. I called for studies of value in generalmust deter us from that conviction. An important compo- thoracic surgery, utilizing the formula that value is propor-nent of this excellence is the Residency Review Committee tional to the quality of outcome and inversely proportional(RRC) in thoracic surgery that sets down criteria for resi- to expense. I called attention to a constant in this formuladencies in the form of special requirements. The RRC eval- that has, in my opinion, been ignored. That constant re¯ectsuates educational programs through a detailed review two observations: (1) patients wish to have their operationsprocess that includes site visits and interviews of the resi- near their homes rather than in distant centers. There is thusdents. Its deliberation result in approval or disapproval of a need in the community for general thoracic surgery; (2)educational programs in thoracic surgery. In short, the RRC many young surgeons who are superbly trained in generalhas authority over programmatic matters; it has no authority surgery are interested in further education in general thor-or responsibility for certi®cation of the graduates of these acic surgery, but they are not so interested in cardiovascularprograms. The American Board of Thoracic Surgery surgery for adults or congenital heart disease. They look for,(ABTS) evaluates each graduate of an approved thoracic but cannot ®nd a residency designed to prepare them for asurgery program. In order to be eligible for ABTS examina- career in general thoracic surgery.tion an individual must be previously certi®ed by the Amer- This year, from South Carolina ± a rural state, the resultsican Board of Surgery (general surgery), and he or she must of a survey of 1583 pulmonary resections were reportedhave completed 2 or 3 years dedicated exclusively to thor- under the title `Specialists achieve better outcomes thanacic surgery in an approved residency. The graduate must generalists for lung cancer surgery [11]. Only 47% ofshow that he or she did a minimum of 125 major operations these operations were done by fully educated and certi®edper year, including a minimum number of cases in each of thoracic surgeons. The general surgeons did signi®cantlythe subspecialties of thoracic surgery. Despite these rigor- more pneumonectomies than the thoracic surgeons, thusous requirements, about 12±20% of the candidates have indicating that the general surgeons chose the easier opera-been unsuccessful in the written examinations which are tion when a lesser but more dif®cult resection such asdesigned to test the knowledge base. Thereafter, about lobectomy or segmental resection might have been better10±15% have failed during their oral examinations which for the patient. The morality rate among patients who hadare designed to test judgement and safety. In recent years, lobectomies by general surgeons was signi®cantly higher asABTS has moved to a so called `criterion referenced exam- compared to the rate among patients whose operations wereination under which there is no obligatory failure rate. There done by thoracic surgeons. When the outcomes wereis the hope that the residencies in thoracic surgery will analyzed according to the patients preoperative co-morbid-become uniformly so good as to allow every candidate to ities it was noted that the death rate among very sick patientspass the ABTS examination. operated by generalists was signi®cantly higher than the death rate among patients whose operations were done by thoracic surgeon. Of additional concern to me was the ®nd-3. Reality ing that 75% of the generalists did less than 10 lung resec- tions for cancer annually and that they were younger than In 1980, in a book entitled The education of American the thoracic surgeons. This information suggests thatphysicians by the historian Gert Brieger chose to give thor- patients and referring doctors are accepting thoracic surgeryacic surgery as an example of a specialty that had grown as a part of the armamentarium of general surgeons who arequickly and changed [2]. He mentioned Sauerbruchs incompletely educated in thoracic surgery. Most suchcontribution that allowed operating in the open chest, Evarts surgeons do thoracic surgery so infrequently that it is safeGrahams well known ®rst successful pneumonectomy and to conclude that they cannot be thinking about thoracicproceeded to discuss the advent of Cardiac Surgery. He said, problems regularly. One can summarize by saying that`By the late 1960s much of the backlog of (congenital heart) more than half of the operations for lung cancer in Southcases had been cleared: coronary artery disease and other Carolina are being done by general surgeons who haveocclusive vascular lesions became important to the thoracic chosen to undertake pneumonectomies when lesser, butsurgeons [9]. In 1981, Donald L. Paulson entitled his presi- more challenging operations might have suf®ced. Highdential address to the American Association for Thoracic risk patients and patients who had lobectomies by generalSurgery `A Time for Assessment` [10]. His concern was that surgeons did more often postoperatively as compared towe were no longer teaching general thoracic surgery well. patients whose operations were by certi®ed thoracicFourteen years later, in my presidential address to the surgeons.Society of Thoracic Surgeons I expressed concern that the There are corroborating data from Europe. In the Nether- Downloaded from ejcts.ctsnetjournals.org by on December 6, 2010
  5. 5. J.R. Ben®eld / European Journal of Cardio-thoracic Surgery 16 (Suppl. 1) (1999) S6±S10 S9lands, the outcome of 344 patients who had thoracic surgery the dif®cult step of taking in these general surgeons after wein 3 centers from 1991 to 1995 was studied [12]. Two of develop mechanisms for evaluating their work. The `goodthese centers had general surgeons doing the operations and guys and girls among the general surgeons would be `grandthe third had fully educated thoracic surgeons practicing fathered, and no new general surgical graduate would betheir specialty. The incidence of pneumonectomies in the granted privileges in thoracic surgery. If a thoracic surgeontwo centers with general surgeons was 34 and 37% as who enters practice in a medium size or small communitycompared to 24% in the thoracic surgical center. Postopera- needs to do some general surgery, I would not object; thor-tive morbidity was higher in the general surgical centers; acic surgeons are after all certi®ed, fully educated generalmortality rates were 10 and 9% in the general surgical surgeons before they undertake additional education. Thecenters and 4% in the thoracic surgical center. fact that a thoracic surgeon does general surgery should not be grounds to exclude him or her from our thoracic surgery organizations.4. Commentary My second recommendation is that we undertake a program to teach the public and physicians in other ®elds In 1996, after my presidency of the Society of Thoracic the value of thoracic surgery. While achieving this goal, weSurgeons, the General Thoracic Surgical Club asked me to must insist on excellence in thoracic surgical education andspeak about my leadership experiences. They chose the title practice. This can currently best be done by keeping general`David (general thoracic surgery) versus Goliath (cardiac surgery certi®cation as a prerequisite for thoracic surgerysurgery). The title took me somewhat aback, but I complied education. We must recognize the currently unmet commu-with the request and enjoyed reading the original story in the nity needs for general thoracic surgery and meet that needbible as the basis for my remarks. As part of my remarks, I by developing a general thoracic track of thoracic surgicaltransposed the message of my STS Presidential Address in education. I purposely do not propose a certain amount ofterms of that biblical epic. I reiterated my belief that general education time for cardiac surgery, general thoracic surgerythoracic surgery and cardiac surgery belong together under or congenital heart surgery. Instead of time, the emphasis inthe umbrella of thoracic surgery. In terms of the story of education needs to be on content and learning. The timeDavid and Goliath, I said that the danger faced by thoracic framework must be secondary to careful consideration ofsurgery is the worldwide atavistic, reactionary trend to content.allow incompletely educated surgeons to operate in the In closing, I wish to look to the future. Before doing so,chest. The Philistines who are the champions of that danger let me mention some of the existing obstacles to surgicalinclude managed care organizations that inappropriately education and the opportunities that will help us to over-believe that it is cost worthy to have all purpose surgeons come these blocks. The ®rst obstacle is the arrogance ofdo thoracic surgery. Administrators cannot and do not look cognitive physicians who paint surgery as a technicalat the quality of patient care until we, the physicians and trade that is beneath them. These are the forces, that claimsurgeons provide data such as that which are emerging from surgical services have been overvalued. A second obstacleSouth Carolina and the Netherlands which show that thor- is the current emphasis on production line ef®ciency inacic surgery done by thoracic surgeons is the most cost health care. Such a mentality does not make allowance forworthy practice of our specialty. education. The concept that undergraduate or postgraduate My ®rst proposal is intended to assure that thoracic surgical students can learn by watching was proven wrongsurgery keep control of general thoracic surgery and set over a century ago. Thirdly, our educational goals arestandards in that sub-specialty. I suggest that we do this blocked by the paucity and progressive shrinkage in fundsby meeting the needs of the patients who wish to be cared allocated to medical education.for as close to home as possible, and the desires of post- The opportunities in surgical education remain enormous.graduate surgical students (residents) who wish to specialize The young people of today are better prepared than we were,in general thoracic surgery. A fundamental step in keeping in part because computer technology can be a terri®c aid tocontrol of thoracic surgery is to measure outcomes. The education. Moreover, the public is now much betterquality of these measurements must be beyond reproach informed than in previous times. Thus, we can enlist theso as to avoid being seen as self serving. I further suggest support the public in our insistence on the maintenance ofthat there may be some general surgeons, who come from high quality in surgical education.`mixed programs such as the one in which I was educated Our host, Professor Anthony Yim laid the groundwork forwho are currently practicing acceptable thoracic surgery. I the future of surgical education in one of his recent publica-accept the reality that it is impossible, and perhaps even tions when he said, `The world of medicine is rapidly chan-undesirable, to stop that practice until an acceptable substi- ging, and the pattern of cardiac surgery at the turn of thetute is in place. These general surgeons currently have no millennium will probably be very different from that weaccess to groups like the STS and the General Thoracic were trained for [13]. Since we cannot predict what thor-Surgical Club, and so they are denied important opportu- acic surgery will be like in the future, education ± not train-nities to keep up with progress. If I were king, I would take ing ± is the key to continuing success. Training is a way to Downloaded from ejcts.ctsnetjournals.org by on December 6, 2010
  6. 6. S10 J.R. Ben®eld / European Journal of Cardio-thoracic Surgery 16 (Suppl. 1) (1999) S6±S10teach followers and repetitive skills. We arrived where we [5] Ben®eld JR. The education and certi®cation of thoracic surgeons. Jare because thoracic surgeons are broadly educated physi- Jpn Assoc Chest Surg 1997;9:98±105. [6] Ben®eld JR. Metamorphosis. Ann Thorac Surg 1996;61:1045±1050.cians who have devoted additional time to surgery. It is the [7] Ben®eld JR. Ad Hoc committee on strategic directions. The Societybreadth of our education that has allowed us to develop ever of Thoracic Surgeons. Strategic directions plan ± 1996. Ann Thoracbetter ways to treat our patients and to adapt to changing Surg 1996;62:613±621.needs. We have come far but the future is further yet. Excel- [8] Ben®eld JR. Thoracic surgery directors association report 1995±1997.lence in surgical education will insure that what is to come The Society of Thoracic Surgeons. Ann Thorac Surg 1997;64:1212± 1215.will be even better than the past. [9] Breiger GH. The education of American physicians. In: Numbers RL, editor. Berkeley, CA: University of California Press, 1980. pp. 202. [10] Paulson DL. A time for assessment. J Thorac Cardiovasc SurgReferences 1981;82:163±168. [11] Silvestri GA, Handy J, Lackland D, et al. Specialists achieve better [1] Celsus A. de Medicina. Cambridge, MA: Harvard University Press outcomes than generalists for lung cancer surgery. 1998;114:675± 1961;3:295. 680. [2] Brieger GH. The education of American physicians. In: Numbers RL, [12] Kappstein AP, Huysmans H, et al. Presented at the European Assoc editor. Berkeley, CA: University of California Press, 1980. pp. 175± Cardiothorac Surg, Brussels, September 1998. 204. [13] Izzat MB, EI-Zuffari MH, Yim APC. Training model for `beating [3] Flexner A. Medical education in the United States and Canada. Carne- heart` coronary artery anastomoses. Ann Thorac Surg 1998;66:580± gie Foundation for the Advancement of Teaching, Boston, MA: 581. Merrymount Press, Bulletin 4, 1910. p. 116. [4] Hertzler AE. The Horse and Buggy Doctor. New York: Harper, 1938. pp. 49. Downloaded from ejcts.ctsnetjournals.org by on December 6, 2010
  7. 7. Surgical education in changing times John R Benfield Eur J Cardiothorac Surg 1999;16:6-10 This information is current as of December 6, 2010Updated Information including high-resolution figures, can be found at:& Services http://ejcts.ctsnetjournals.org/cgi/content/full/16/suppl_1/S6References This article cites 8 articles, 4 of which you can access for free at: http://ejcts.ctsnetjournals.org/cgi/content/full/16/suppl_1/S6#BIBLPermissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://ejcts.ctsnetjournals.org/misc/Permissions.shtmlReprints Information about ordering reprints can be found online: http://ejcts.ctsnetjournals.org/misc/reprints.shtml Downloaded from ejcts.ctsnetjournals.org by on December 6, 2010