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- Michael J. Mack, MD (, )@TheDoctorMack
Han and colleagues, cardiac surgery fellows-in-training, expressed their anxiety regarding the rapid changes in clinical practice encountered during training in cardiac surgery and provided some solutions as to how to adapt to these uncertainties. They term their understandable angst “transition within a transition.”
Historically, the specialty of thoracic surgery has always been, as Han states, one of “paradigm shifts” or, as euphemistically referred to within the specialty, “staying one operation ahead of extinction.” To wit, the specialty began as one to treat tuberculosis until the introduction of sulfa drugs greatly diminished the role of surgery for that disease. The specialty then evolved to the management of rheumatic heart disease for which surgery was a mainstay of treatment until penicillin dramatically reduced the incidence of the disease in developed countries. Next, the central role of surgical coronary revascularization in the treatment of coronary artery disease was significantly modulated by the introduction of percutaneous coronary intervention. Furthermore, many other procedures began as thoracic and cardiac surgical procedures, including bronchoscopy, esophagoscopy, permanent pacemaker, defibrillator implantation, and insertion of intra-aortic balloon pumps, only to have those procedures move to other specialties as the devices become smaller and more easily implanted without general anesthesia. Despite the evolution in the core treatments delivered by our specialty in different eras, we have not become extinct, nor has the specialty diminished; rather, it has survived and thrived.
Now, as the authors adroitly point out, we are in the midst of yet another paradigm shift in our specialty occurring while they are in the midst of their training. Thoracic aortic disease, including even acute ascending aortic dissection, is evolving rapidly to a largely endovascular approach. Valvular heart disease, especially aortic stenosis but also mitral and tricuspid regurgitation, are now being increasingly treated by transcatheter approaches. The question is, therefore, for not only trainees in cardiac surgery but also for cardiology fellows in training: how do we adapt to this latest transition? The American Board of Thoracic Surgery recently added requirements for cardiac surgery trainees aspiring to board certification to gain experience as a primary operator for transcatheter aortic valve replacement. But it has been quickly realized that this experience is woefully insufficient for trainees to gain expertise in the burgeoning field of structural heart disease. To address this, specialty societies in cardiology and cardiac surgery are in the process of developing a formal certified training pathway for both cardiologists and cardiac surgery trainees to gain the necessary skills for the management of patients with valvular and structural heart disease in the future.
As I reflect on the types of operations I was performing when I finished training in 1982, they bear little resemblance to the procedures being performed today. However, that offers little solace to the trainee whose sands are now shifting beneath her/his feet. As the Greek philosopher Heraclitus stated, “the only constant is change” (1). You cannot worry too much that you chose the wrong career path or succumb to the fear that you will be left behind. Rather, embrace what you love to do and be cognizant of the changes in the ecosystem in which you work. Learn to lead change, embrace that which is currently good, have the vision to determine what needs to change, and have the wisdom to know the difference. To paraphrase Charles Darwin, it’s not the strongest of a species that survives, or the most intelligent, but the one most responsive to change.
- 2019 American College of Cardiology Foundation
- ↵Heraclitus of Ephesus. The Cosmic Fragments. c. 500 BC.