The Thoracic Surgery Directors Association (TSDA) has a relatively brief 20 year history which is best understood within the context of the influence leading to its establishment as a formal organization in 1978. The need for a forum for physicians with a common interest in the newly emerging field of thoracic surgery resulted in the founding of the American Association for Thoracic Surgery under its first president, Dr. Willy Meyer, in 1917. However, it was not until 1928 when the first organized training program for thoracic surgeons was formalized by Dr. John Alexander at the University of Michigan in 1928. His dictum of two years of dedicated training in thoracic surgery after completion of a residency in general surgery was to govern thoracic surgical resident education for more than 60 years. Since the specialty of thoracic surgery developed through the efforts of general surgeons, the field was initially considered a part of general surgery, and the hospitals for chest disease and the sanatoria for the treatment of tuberculosis were regarded as specialty training opportunities for trainees in general surgery.
The Board of Thoracic Surgery was established as an affiliate board of the American Board of Surgery in 1948 to provide certification for thoracic surgeons. Initially, in order to be certified by this Board, the candidate was required to pass an oral examination and to demonstrate high moral and ethical standards; there was little emphasis on the quality of thoracic specialty training. Over the ensuing years, both the number of training programs and candidates for the Board examination increased, and the Board of Thoracic Surgery formalized more stringent criteria for eligibility. In 1966, the Board disqualified one-year residency training programs, and in 1968, it voted to require that applications for the examination be signed by the chief of the candidate's thoracic surgery training program and that every candidate have an identifiable 12 month period of senior clinical responsibility.
In 1971, the Board of Thoracic Surgery severed its affiliation with the American Board of Surgery and became a separate primary Board, changing its name to the American Board of Thoracic Surgery. Criteria for credentialing were further defined, and in 1978, the Board voted that only candidates completing training in approved residency programs would be eligible for the certifying examination. As the ABTS was being established in 1966, the Board of Thoracic Surgery along with the AMA Council on Medical Education formed a bipartite residency review committee. The American College of Surgeons became the third parent organization of the Residency Review Committee for Thoracic Surgery in 1970. The RRC subsequently formulated and published guidelines for essentials in thoracic surgery training, including minimum numbers of cases for adequate operative experience by the trainee and the appropriate distribution of the operative experience. A process for periodically reviewing programs and designating them as fully approved, provisionally approved, or probationally approved was established, insuring more consistent and higher quality residency training in thoracic surgery.
At the same time that the American Board of Thoracic Surgery and the Residency Review Committee were exerting their influence on thoracic surgical training in this country, a group of the thoracic surgery programs began to meet informally, for the first time at the annual meeting of the Society for Thoracic Surgeons in 1970. They were concerned that thoracic surgical training was being molded, directed, and dictated by forces external to the directors, who had the immediate responsibility for residency training. These initial meetings provided little more than a forum for airing the concerns of the directors. However, under the guidance of Dr. Hassan Najafi, this group was formally organized as the Thoracic Surgery Directors Association (TSDA) and incorporated in 1978, at which time Dr. Najafi, the first president of this new organization, and Dr. Benson Wilcox, the Secretary, drafted by-laws which were approved by the Association. The objectives of the Association emphasized its mandate to improve thoracic surgery resident education and to facilitate the solution of administrative problems arising in the conduct of thoracic surgery training programs. Membership was limited to directors of approved residency training programs. Standing committees were established, including one for Consultation to assist directors with administrative problems of their individual programs; one on Curriculum and Education to focus on deficiencies in the thoracic surgery curriculum and methods for their correction; and one for developing an In-Training Examination.
Retrospectively, the initial enthusiasm and commitment of the TSDA to resident education seemed to quickly dampen as the extraordinary technical achievements in myocardial revascularization occurred, and coronary artery bypass surgery dominated the specialty of thoracic surgery, and exerted a disproportionate influence on both our clinical practices and our training programs. The shear volume of the clinical workload generated by the phenomenon of myocardial revascularization greatly affected the balance between resident service and education in thoracic surgery. But this negative influence on thoracic surgery resident education was not to go unnoticed.
In 1981, in his presidential address to the American Association for Thoracic Surgery entitled " A Time for Assessment," Dr. Donald Paulson expressed a growing concern of a number of leaders in the specialty about the status and future of general thoracic surgery. The tremendous technological advances in cardiac surgery since the early '50s and the impact of myocardial revascularization had relegated general thoracic surgery to a secondary role, and at many hospitals, segments of this field had already been lost by default to surgeons with minimal thoracic training. Responding to Dr. Paulson's recommendations, the Council of the AATS later in 1981 appointed the Liaison Committee for Thoracic Surgery which was charged with preserving "unity of the specialty through achievement of appropriate balance in each division of training, in the interest of competence and delivery of quality health care."
During the 1980s, the Liaison Committee in a series of questionnaires to program directors, editorials in the Journal of Thoracic and Cardiovascular Surgery and the Annals of Thoracic Surgery, and reports and recommendations to the Council of the AATS championed the cause of general thoracic surgery. These efforts served as a catalyst that ignited interest in what a broad-based thoracic surgery residency should be and emphasized just how great the imbalance between service and education had become for thoracic surgery residents. The TSDA did not take a proactive position on this subject, however, and during the '80s, although it discussed at its meetings topics relevant to the program directors, little substantive direction was provided by this organization.
The 1990s have ushered in a veritable crusade on behalf of thoracic surgery resident education. In 1991, an editorial symposium on thoracic surgery education appeared in the Annals of Thoracic Surgery. Later that same year, Dr. John Waldhausen, President of the American Association for Thoracic Surgery, responded to the expressed concerns about the direction that thoracic surgery education had taken. Questions were raised as to whether American cardiothoracic surgery is still attracting the brightest and the best graduates of our medical schools and what the field of thoracic surgery is to be in the future. How should future thoracic surgery residents be educated? What should be the direction of future research? How should this be funded? How do we as thoracic surgeons relate to the technologic and socioeconomic changes occurring around us? To begin to focus upon these difficult issues, Waldhausen convened a retreat of some of the leadership of thoracic surgery in Snow Bird, Utah, on September 20, 1991. Approximately 50 individuals attended the conference which was divided into five separate workshops on the following topics: resident education, the scope of cardiothoracic surgery, future directions of research, funding for cardiothoracic surgical research, and the cardiothoracic surgeon and social responsibility. Recommendations regarding thoracic surgical education arising out of the Snow Bird conference were as follows: (1) maintain the integrity of cardiothoracic surgery by providing integrated training in both general thoracic and cardiac surgery; (2) improve the educational environment of thoracic surgery residents by reducing the service load and emphasizing the educational nature of residency; (3) establish a core curriculum for thoracic surgery; (4) permit residents to obtain specialized training within the field of thoracic surgery if they so desire (e.g., in congenital heart disease, general thoracic surgery, heart or lung transplantation); (5) examine the need to retain American Board of Surgery certification; and (6) attempt to better integrate once again general and thoracic surgical resident education.
The cauldron was now boiling as the emphasis clearly shifted to providing quality thoracic surgical resident education. We were chastised by Dr. Ward Griffin, Secretary of the American Board of Surgery, that the term "residency training program" was now socially unacceptable in the light of our discussions. He reminded us that "You train dogs and horses. You educate residents." And even before the AATS Snow Bird conference was convened, Dr. Benson Wilcox was appointed Chairman of the STS Ad Hoc Committee on Graduate Education in Thoracic Surgery which set about to further analyze current opinions regarding thoracic surgery residency and to develop an objective profile of the contemporary thoracic surgery resident. The results of these analyses were the focal point of a Joint Conference on Graduate Education in Thoracic Surgery organized by the Ad Hoc Committee and convened on October 25-27, 1992, at Oak Brook Hills, Illinois, under the sponsorship of the AATS, the ABTS, the Coordinating Committee for Continuing Education in Thoracic Surgery (CCCETS), the STS, and the TSDA. This retreat was focused entirely upon thoracic surgery resident education and was structured as a consensus conference with initial work groups discussing thoracic surgery in the year 2010, recruitment of the brightest and the best, thoracic surgery curriculum, residency environment, and the certification and accreditation process in our specialty. The attempt was to begin to identify essential needs and deficiencies within our current system of resident education. It now became clear that the original justification for establishment of the Liaison Committee by the Council of the AATS in 1981 was no longer operational. In fact, the need for the AATS to form a committee to confront the imbalance between service and education in our thoracic surgery residencies was an overt acknowledgment of the inadequate influence of the thoracic surgery program directors - the stewards of thoracic surgery resident education - who should have begun to address this issue even before that time. The Thoracic Surgery Directors Association had been remiss in its basic obligation of being an advocate and protector of quality thoracic surgery education.
Subsequently, in response to the pressure for an improved educational process for our residents, the TSDA has assumed a new commitment to its leadership role in thoracic surgery resident education. The Liaison Committee of the AATS was now felt to be superfluous, and the committee was therefore dissolved by the Council of the AATS in October 1991. With a renewed mandate to thoracic surgery residents, in 1992, the TSDA established a uniform national Matching Program for residency selection in order to provide its general surgery resident applicants a consistent, orderly, and fair selection process. The by-laws of the Association were updated and amended in 1993. Participation in the Matching Program became a prerequisite for membership in the TSDA, and Associate Membership status was established for one individual from each director's program who was also interested in resident education. As an acknowledgment of the growing influence which the TSDA was expected to have in resident education, at its April 1992 meeting, the American Board of Thoracic Surgery voted to change its organizational framework to include two representatives from the TSDA.
In 1993, the TSDA initiated its Comprehensive Thoracic Surgery Curriculum Project, the goal of which was to reach consensus on the scope of study that should be encompassed in thoracic surgery residency. Endorsed by the American Board of Thoracic Surgery, the Residency Review Committee for Thoracic Surgery, the AATS, and the STS, and with input from multiple Program Directors and thoracic surgery faculty, the Curriculum outline was developed under the co-editorship of Drs. Stanton P. Nolan and Robert K. Salley. The TSDA Comprehensive Thoracic Surgery Curriculum was published in 1994 as a guide for study and appropriate clinical activities during thoracic surgery residency and an aid to Program Directors in structuring their programs. The Comprehensive Curriculum encompasses the entire specialty of thoracic surgery (adult and pediatric cardiac surgery and general thoracic surgery) and is divided into 14 studies units, each consisting of four parts: Unit Objective (the rationale for the unit); underlying Learner Objectives (the knowledge to be acquired by the resident); Contents (the study needed to achieve the objective of the unit); and Clinical Skills (the clinical activities and technical tasks felt to be necessary for the resident to become an independent and safe thoracic surgeon). Within the Comprehensive Curriculum, those Learner Objectives and Clinical Skills deemed "essential" (i.e., the minimum necessary requirements) were highlighted. This Comprehensive Thoracic Surgery Curriculum was an extremely important milestone in the history of the TSDA as it represented the first attempt to define the basic educational goals that should be met by every thoracic surgery residency program. Implicit in adoption of the Comprehensive Curriculum was an understanding that it represented a dynamic document which would have to be reviewed and updated at three to five year intervals.
Shortly after publication of the Comprehensive Curriculum, TSDA leadership recognized that a printed outline was only the beginning of a process intended to improve the education of thoracic surgery residents. Implementation of the Curriculum was the obvious next step and is clearly a more complicated process. Under the leadership of President John Benfield, the first freestanding meeting of the TSDA was held in Chicago from September 6-7, 1996. At this Retreat, six work groups discussed and brought forward recommendations on the following topics:
1. funding of thoracic surgery residency
2. the Prerequisite Curriculum
3. thoracic surgery-general surgery relations
4. thoracic surgery subspecialty education (tracking)
5. American Board of Surgery certification
6. the future of the TSDA in thoracic surgery education.
One of the more significant recommendations was greater emphasis of the TSDA on curriculum implementation.
As another indication of its maturity as a national organization, in 1997 the TSDA selected Mr. Tom Fise, President of Association and Government Relations Management, Inc., as Executive Director to provide professional administrative and management services for the Association.
During the past two years, the TSDA has made substantial efforts to achieve curriculum implementation. At its May 2, 1998 meeting, the Directors ratified revised by-laws which established three new standing committees:
1. The Requisite Curriculum Committee, responsible for updating the Thoracic Surgery Comprehensive Curriculum at no less than 3 year intervals;
2. The Curriculum Implementation Committee, responsible for developing the optimal methodology whereby the Comprehensive Curriculum is taught to thoracic surgery residents;
3. The Prerequisite Curriculum Committee, responsible for defining, developing, and implementing, where appropriate (a) the general surgical curriculum (core knowledge) and (b) the thoracic surgery curriculum (core knowledge) deemed essential for residents beginning their thoracic surgery education.
Each of these committees is now functioning and working to meet its charge. Based upon the rapidly evolving advances in medical information technology, the goal is to develop interactive electronic formats for better and more uniform transmission of information to our residents. Corporate sponsorship as well as funding from the Thoracic Surgery Foundation for Research and Education is being sought to support the development and dissemination of the new interactive programs being developed. The second freestanding meeting of the TSDA was held in Chicago on September 18-20, 1998. The focus of this program was further discussion of principles of education, mentorship, and the means whereby the educational efforts of thoracic surgery residency programs can be improved The TSDA has reached sufficient maturity for a separate annual national meeting devoted entirely to educational issues affecting our residency programs. The balance between service and education in thoracic surgery residency education is precarious, and there is clearly resolve among the TSDA to pay more attention to this balance.
