Cardiothoracic surgeons look to reinvention in age of minimally invasive procedures

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WASHINGTON—In no uncertain terms, W. Randolph Chitwood Jr., MD, told an audience heavily populated with cardiac surgeons that “we must reinvent ourselves.”   

Chitwood, chief of the division of cardiothoracic surgery at East Carolina University School of Medicine in Greenville, N.C., spoke on Tuesday at the 20th annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium.

Various forces are acting to bring about this change, he said, including a population that is older, sicker and at higher risk for complications. Chitwood added that patients often perceive minimally invasive procedures are more efficacious than open surgery even when the data do not support it.

Additionally, an onerous residency-training program and the ensuing debt, resident work hour restrictions and lifestyle changes are contributing to a shortage of cardiothoracic surgeons. In 2006, only about half of the 130 available cardiothoracic surgery residency slots were filled, he said.

Turf issues, health policy pressures, public reporting and pay for performance are all part of the changing the surgical landscape, aspects that “our forefathers did not have to consider,” Chitwood said.

Many traditional operations have been supplanted by either percutaneous methods or pharmaceutical therapy.

Cardiothoracic surgical trainees want to learn minimally invasive operations including endoscopic and robotic, catheter-based interventions for the thoracic aorta, carotids, coronary arteries and valves. They also want to learn imaging technology, such as echo, CT and MR angiography to help plan operations.
They also want modern critical care training and other nontraditional skills such as practice management and biostatistics, a reasonable training period such as six years, collaboration with cardiologists and vascular surgeons and a reasonable lifestyle, Chitwood said.

“If we as surgeons want to respond to the clarion call, we must plan to adapt to what our trainees need,” he said.

In response to the changing landscape, Chitwood and others have recently created the Joint Council for Thoracic Surgery Education (JCTSE). The mission of JCTSE is to update the curriculum and create uniform and standardized training to provide a solid foundation, heavily influenced by technology training.

Chitwood said a focus of JCTSE will be to ensure residents get cross-specialty imaging training and collaborative training such as an interventional year spent in the cath lab.

“Eventually, we may have to unify the training of cardiovascular specialists, and that may be touching the third rail,” Chitwood said, referring to the electrical subway tracks rail. “But this is where it has to go because we each bring something to the table—the surgeon, cardiologist and vascular surgeon.”

There are three options for training, Chitwood said:
• Three years of a surgical core and three years of cardiovascular training
• Five years of general surgical training and three years of cardiovascular training (the traditional approach), and
• Right of medical school, no general surgery but five to six years of cardiovascular training, with a specialized program in cardiothoracic surgery.
The curriculum does not have to be dependent on the American Board of Surgery requirements, which they have dropped, Chitwood said. Rather, requisites for success as a cardiothoracic surgeon today, are:
• echocardiography
• wire skills
• electrophysiology
• vascular and molecular biology
• thoracic oncology
• endovascular surgery
• interventional radiology
• imaging such as CT, MR and angiography
• pulmonary medicine
“All of these are necessary for the cardiothoracic specialist,” he said.

Chitwood and colleagues are trying to develop a “Top Gun” school approach over the next five years to train residents. “We want the best of the best,” he said.

The good news for cardiothoracic surgeons is that there is plenty of work. Between 1999 and 2004, all cardiothoracic procedures grew by 14 percent. CABG decreased by 8.4 percent, but all procedures by cardiac surgeons increased by 38 percent.

To make up for the drop in CABG procedures, Chitwood suggested designing a surgical therapy for atrial fibrillation that is “minimally invasive or least invasive, off pump, that works 95 percent of the time.” He added, “There are more patients out there with a-fibrillation than there are with coronary artery disease, as far as surgeons are concerned.

There has also been a decrease in the number of active surgeons, leaving more work for the younger generation. As a sign of the times, Chitwood said that if the market stays the way it is, no one will retire. “We’re going to die right three on the pump.”

“We will prevail as a specialty,” he said,” as long as we can morph into a new life form.”