Interact CardioVasc Thorac Surg 2006;5:236-237. doi:10.1510/icvts.2005.126904
© 2006 European Association of Cardio-Thoracic Surgery
Brief communication - Vascular thoracic |
How to retrain the cardiothoracic surgeon
Grayson H. Wheatley and
Edward B. Diethrich*
Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute, 2632 N. 20th Street, Phoenix, AZ 85006, USA
Received 16 December 2005;
accepted 20 January 2006
 Presented at the 41st Annual Meeting of The Society of Thoracic Surgeons, Tampa, Florida, January 24, 2005 (Tech-con Conference).
*Corresponding author:. Tel.: +1-602-240-6165; fax: +1-602-240-6161.
E-mail address: ediethrich{at}azheart.com (E.B. Diethrich).
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Abstract
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It is both an exciting and challenging time for cardiothoracic surgeons. Declining case volumes and diminishing reimbursement are causing a major disruption in the way practicing cardiothoracic surgeons approach their specialty and graduating cardiothoracic surgery residents seek employment. However, new advances in the treatment of cardiovascular diseases, such as endoluminal grafting for diseases of the thoracic aortic, are rapidly becoming available. It will take a significant commitment on behalf of busy practicing cardiothoracic surgeons to ‘retrain’ and develop the necessary skill-set to become proficient in catheter-based therapies and other emerging therapeutic modalities. We review the factors that contributed to the rise of cardiothoracic surgery as a specialty, the current state of the specialty and the potential that endovascular surgery offers cardiothoracic surgeons and examine the obstacles and solutions for retraining cardiothoracic surgeons.
Key Words: Cardiovascular diseases; Retraining
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1. Introduction
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It is both an exciting and challenging time for cardiothoracic surgery. Declining operative case volumes and diminishing physician reimbursement are substantially impacting cardiothoracic surgeons' practices, and are causing significant concern about the future direction of their specialty. Catheter-based interventions are threatening the viability of traditional cardiac surgical practices. A ‘scorecard’ across all procedures demonstrates losses in all areas (Table 1). A parallel loss has also occurred in our training programs with associated evidence that these changes are affecting the job market for graduating residents. A recent survey of graduating United States cardiothoracic surgery residents reported that almost 20% of graduating residents received no job offers [1]. We believe a closer look is needed at novel approaches for ‘retraining’ the cardiothoracic surgeon for the future.
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2. Looking to the future
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Cardiovascular care is rapidly moving toward catheter-based technologies, and many cardiothoracic surgeons are looking for ways to become involved. However, there are a number of impediments confronting cardiothoracic surgeons as they look to get involved with endovascular procedures. First, cardiothoracic surgeons lack the skill set to perform catheter-based interventions. Endovascular techniques are not currently part of the standard cardiothoracic surgeon's practice, nor are catheter skills part of the required residency training program curriculum [2]. As a result, cardiothoracic surgeons are not able to rapidly incorporate these technologies into their practice, making them less competitive with specialists, such as vascular surgeons and interventional radiologists. Endoluminal grafting for thoracic aortic disease is an involved process and cannot be learned in a weekend or even a month long course. In addition, to wire skills, vascular access for thoracic aortic procedures is an important consideration, and involves skills such as retroperitoneal conduits, management of delivery complications and brachial-femoral wires. Thoracic endografting also offers a unique opportunity for hybrid procedures involving a great vessel debranching and deployment of an endoluminal graft into the aortic arch (Fig. 1).
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Fig. 1. Hybrid procedure involving a debranching of the great vessels and placement of an endoluminal graft into the aortic arch.
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Another impediment for cardiothoracic surgeon retraining is the ‘No workshop’ problem. High-quality imaging is imperative for high-quality results. Access to high quality imaging for endovascular procedures such as an endovascular suite with a ceiling mounted C-arm is usually not available to the cardiothoracic surgeon. Oftentimes access to these imaging modalities is controlled by other specialists who are not interested in involving the cardiothoracic surgeon. At the Arizona Heart Institute, all of our operating rooms have a ceiling mounted C-arm, flat panel LCD displays and radioopaque procedure tables. We believe that each of these components are necessary when performing endovascular procedures.
There are competitive and economic roadblocks to physician retraining. The already established interventionalists may not be eager to train or share revenues with the cardiothoracic surgeon. Another economic roadblock is practice income. To adequately learn endovascular techniques and become proficient in catheter-based therapies takes a long time, sometimes 6 months or more. It will take a significant commitment on behalf of busy practicing cardiac surgeons to ‘retrain’ and develop the necessary skill-set to become proficient in catheter-based therapies and other emerging therapeutic modalities.
A number of potential solutions are available. Cardiothoracic surgeons interested in becoming involved in endovascular procedures should begin by visiting a nationally-recognized, high volume clinical setting where these new procedures are being performed. By observing the way in which new technology is being applied, the surgeon can become more comfortable with the clinical indications and infrastructure necessary to implement new treatment modalities into their own practice. Second, the surgeon should partner with someone in their own community who is already involved in the new procedure, even if it means collaborating with a cardiologist, vascular surgeon or interventional radiologist.
In addition, cardiothoracic surgeons should attend a short, intensive course to develop hands-on experience. When the surgeon feels comfortable with the techniques, they should invite a ‘proctor’ to assist with their first several cases. Another option is to spend 6 to 12 months obtaining formal endovascular training at a high-volume endovascular center of excellence. Finally, and probably the most difficult aspect, is to obtain privileges in your institution for the desired procedures. Many professional societies are developing a set of endovascular surgery credentialing guidelines which may be of assistance in obtaining hospital privileges. Perhaps a more sustainable approach would be to establish cooperative collaborations at the national societal level with other cardiovascular specialists including vascular surgeons, interventional radiologists and cardiologists.
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3. Summary
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Retraining cardiothoracic surgeons opens a Pandora's box of related issues such as specialty competition and economic barriers. The skills, knowledge and access to imaging resources gained through acquiring endovascular procedures will potentially assist cardiothoracic surgeons in becoming involved in future treatment advances such as percutaneous heart valves and cellular therapies for heart failure. New training paradigms in cardiovascular medicine and surgery could attract new resident applicants and lead to a new model for the delivery of cardiovascular health care. The future could not be brighter for those who are willing to adapt, innovate and conquer the challenges like our forefathers of cardiothoracic surgery did 40 years ago.
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References
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- Salazar JD, Lee R, Wheatley GH, Doty JR. Are there enough jobs in cardiothoracic surgery? The thoracic surgery residents association job placement survey for finishing residents. Ann Thor Surg 2004; 78:1523–1527.[Abstract/Free Full Text]
- Wheatley GH. A recent graduate's perspective on residency training. Ann Thorac Surg 2005; 80:382.[Free Full Text]
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Abstract
1. Introduction
