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How to train best heart surgeons? Prominent cardiac surgeon and educator shares wisdom. 9
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. I spoke to a neurosurgeon in California who said the remarkable phrase. “The genius within is the genius you can pass on”. Dr. Anton Titov, MD. You have a particular interest in training cardiac surgeons in minimally invasive heart surgery techniques. You train young surgeons in transcatheter aortic valve replacement. Dr. Anton Titov, MD. What is your approach to the modern cardiac surgery training? Dr. Marc Pelletier, MD. Cardiac surgery training is a bit like an apprenticeship. Our cardiac surgery residents are just tremendous smart young women and men that come and train. Surgery residents really just want to do a good job, they want to be able to master their craft. For us, cardinal surgeons, training a little bit different than in internal medicine. Internal medicine is very intellectually-based. It is very patient assessment-based. Dr. Marc Pelletier, MD. For us in surgery there is such a strong technical component. Surgery residents come, and they are under our wings. Our job is that at the end of their six or eight years of training that they are competent cardiac surgeons. Dr. Marc Pelletier, MD. Young surgeons must be able to take care of patients. People always ask us about young surgeons. “How do I know that somebody is well trained?” We say. “Sometimes 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? Can they do it safely and competently?” Dr. Marc Pelletier, MD. That is a process that really takes many many years. The most important thing when we are 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 are doing. Dr. Anton Titov, MD. Young surgeons have to know everything about the patients they are treating. They must know who should be treated and who should not be treated. vSurgeons have to know what kind of options patients should be given. But #2 point is. the most important. Dr. Marc Pelletier, MD. Cardiac surgery residents need to come out of a surgery training program as good technical safe surgeons. Surgeons need to be able to get through an operation very safely. They need to be able to do the correct technical operation. They have to protect the heart. They have to stop the heart. Surgeons have to do the coronary bypasses. They must be able to 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. That process is challenging sometimes for us and for trainee surgeons. Dr. Marc Pelletier, MD. Surgeons need to be in the operating room. They first need to watch how we do cardiac surgery. Little by little we let trainee surgeons 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. As the years and years progress, surgeons get to a point where they can really do the entire operation from start to finish. Surgeons can do it with some supervision or minimal supervision. The challenges that these trainees are facing now is that cardiac surgery has evolved. Cardiac surgery now is a different specialty. 15 or 20 years ago we were operating on many of the easy patients. Easy patients are now not coming to cardiac surgery. Patients are having coronary artery stents. Patients may need a very simple aortic valve replacement. Dr. Anton Titov, MD. They are now going to have a TAVR procedure. The patients that are actually having cardiac surgery now are much more complex. Dr. Marc Pelletier, MD. I can look at my patient list now and compare it to what it was 15 years ago. Cardiac surgery operations now take longer. cardiac surgery is more difficult. How do you teach somebody all that complex heart surgery on difficult patients? Operations that young surgeons are doing are more complex. We used to do many more routine cardiac surgery. We are giving our surgery residents an opportunity to treat complex patients. Teaching surgeons to do complex operations is a challenge. Then on top of that we are trying to add in newer surgical techniques. There are minimally invasive surgery techniques. Dr. Marc Pelletier, MD. These new surgery methods are great for the patient. But a small incision means that it is more difficult for the surgical resident to learn new technique. It’s more difficult for the young surgeon to see what we’re doing. It is more difficult for us to teach a minimally invasive heart surgery technique. This is a little bit more technically challenging, it’s a little bit harder. Dr. Anton Titov, MD. How do you incorporate new surgical methods as part of the teaching? It’s something that we struggle with all the time. For us the goal is that we want surgical trainees to be in the operating room. We want to give young surgeons graded responsibilities as they gain more experience. We want to make sure that young surgeons maintain their confidence. We cannot give them tasks that they are not able to do. Dr. Marc Pelletier, MD. Young surgeons must increase their level of skill as time goes on. When we are performing heart surgery through small incisions, we must have good video capture. We must have good video capability. Therefore, young surgeons can see what we are doing on a screen. At least trainee surgeons do not have to look into a small incision. Heart surgery incision might be two or three inches in size. Those are the challenges that we face. You are going to see surgery training programs that are no longer training cardiac surgery residents. Because surgery residents must have a certain volume of cardiac surgery patients. Cardiac surgery residents must perform a certain number of cases. Dr. Marc Pelletier, MD. There are probably some cardiac surgery training programs out there that have gone down in terms of their numbers of surgeries. We have seen already that some cardiac surgery programs are no longer teaching residents. Dr. Anton Titov, MD. But large cardiac surgery programs can provide residents with a good broad experience. It is essential for where residents are going to train.
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