How to train best heart surgeons? Prominent cardiac surgeon-educator shares views
Open heart surgery and minimally invasive cardiac treatments get ever more complex. How to train future leaders in cardiac surgery and interventional cardiology?
– Let’s talk about cardiac surgery training. And I spoke to a neurosurgeon in California who said the remarkable phrase: “The genius within is the genius you can pass on”. You have a particular interest in training cardiac surgeons in minimally invasive heart surgery techniques, in transcatheter aortic valve replacement. What is your approach to the modern cardiac surgery training? Cardiac surgery training is a bit like an apprenticeship. These residents – and they’re just tremendous smart young women and men that come and train, and surgery residents really just want to do a good job, they want to be able to master their craft. And for us it’s a little bit different than, for example, internal medicine, where it’s very intellectually based and it’s very patient assessment based. And for us in surgery there’s such a strong technical component. So these residents that come, and they’re under our wings, our job is that at the end of their six or eight years of training that they are competent cardiac surgeons and that they can take care of people. We always talk about surgeons, “How do I know that somebody is well trained?” We say, “If I have to go away and he’s in charge or she’s in charge of my patients, are they able to do the operation that needs to be done? And can they do it safely and competently?” And that’s a process that really takes many many years. The most important thing when we’re training residents is that, first of all, we have to help them acquire the proper knowledge base. They have to be very knowledgeable, comprehensively, about what they’re doing, the patients they’re treating, who should be treated, who should not be treated and what kind of options they should be given. But #2, and most importantly, is that they need to come out of a surgery training program as good technical safe surgeons, that they need to be able to get through an operation very safely, they need to be able to do the right thing, protect the heart, stop the heart, do the coronary bypasses, replace the heart valve. They need to be able to technically do that. They don’t need to be superstars but they need to be able to do it safely and very well. And that process is challenging sometimes for us and them. They need to be in the operating room. They first need to watch how we do it, and little by little we let them put in some sutures here, some sutures there. We let them do a small part of the operation, then a bigger part of the operation, so that as the years and years progress, they get to a point where they can really do the entire operation from start to finish with some supervision or minimal supervision. The challenges that these trainees are facing now is that cardiac surgery has evolved to a specialty where many of the very easy cases that we were doing 15 or 20 years ago are now not coming to surgery, patients are having stents or the very simple aortic valve replacement is now going to be a TAVR procedure, so the patients that are actually having surgery, if I look at my list now compared to what it was 15 years ago, they’re much more complex, the operations tend to take longer. So how do you teach somebody all those things, when the operations that they’re doing in fact are more complex than the more routine ones that that we used to do? So giving residents that opportunity to take those complex patients through surgeries is a little bit of a challenge. And then on top of that we’re trying to add in newer techniques, minimally invasive techniques, which are great for the patient. But a small incision means that that resident – it’s a little bit more difficult for that person to see what we’re doing – and for us to teach that technique, which is a little bit more technically challenging, it’s a little bit harder. So how do you incorporate that as part of the teaching? It’s something that we struggle with all the time. For us the goal is that we want them there in the operating room, we want to give them graded responsibilities as they go on, we want to make sure that they maintain their confidence, that we don’t give them things that they’re not able to do. So that they can really increase their level of skill as time goes on. And when we’re doing things through small incisions that we have good video capture, that we have good video capability, that they can see what we’re doing on a screen, at least without having to look into a small incision that might be two or three inches in size. So I think those are the challenges that we face, and I think you’re going to see surgery training programs that, unless residents have a certain volume and a certain number of cases, there are probably some cardiac surgery training programs out there – and we’ve seen that already – that have gone down in terms of their numbers, or are no longer teaching residents. I think large programs that can provide residents with a good broad experience is essential for where residents are going to train.