The purists would say that the original and true purpose of a scientific meeting is to communicate new data of ongoing or completed research. The objective here is to disseminate new information, as it is on its way to becoming knowledge. Very importantly, it gives the presenter the opportunity to discuss observations and criticisms about their work. I still believe that this is a seminal purpose of the meetings in Thoracic Surgery.

However, with the frenetic pace of science, the internet, and the explosion of information that is available, how is it that the scientific meeting survives to achieve this seminal purpose? I speculate that just like newspapers and books survive, so does the presenter in front of the podium. Nothing can substitute a face-to-face discussion surrounding a question or a problem. True insight into someone’s research is only gleaned this way.

But this is the idealist’s view. In reality, to really judge and critique research, it is necessary to review the published manuscript (and sometimes even then it is difficult). Nevertheless, there is value added in speaking with the investigators.

For me, the research aspect of a meeting is a great source of new ideas and it renews my enthusiasm to support and participate in such research endeavours. This is the interesting part.

Most of us are simple practitioners of clinical thoracic surgery and our purpose in attending meetings is to be educated. Pure research discussions may be of little relevance to the average surgeon because only rarely can the research be applied immediately to clinical practice. It is the educational component of the meetings that attracts many of us. It is an opportunity to listen to expert opinions. If one really wanted an educational experience, it would be better to attend meetings that emphasize reviews of topics or approaches to difficult clinical problems. These often contain research in the form of posters. Most, if not all, scientific meetings include some educational course or the like. This is a rewarding part of the whole affair.

Meetings are also business events. It is an opportunity for the members of the societies to meet and discuss relevant business (regulations, policies, by-laws, statements, guidelines, direction, etc). There is not much more to say about this.

Meetings are also great social events. You can meet old friends and make new ones. I would describe this aspect of a meeting as networking. Networking is very much part of our lexicon and our behaviour. It is part of being a social animal. To network is to interact or engage in informal communication with others for mutual assistance or support (American Heritage Dictionary, 4th edition). I could not have put it more eloquently. Oh, how I do love the clarity of definitions! There is no contempt in my observation. I just put it forward as something obvious. I believe networking is necessary to build alliances and create opportunities. Yet it must be done in a dignified way.

Networking must not be confused with “schmoozing”. To schmooze is to converse casually, especially in order to gain an advantage or make a social connection (American Heritage Dictionary, 4th editions). Again, the lucidity of this definition I cannot surpass. The purpose of networking and schmoozing is similar, but the latter behaviour is more perverse and, certainly, not dignified. This is the disappointing part. *

Meetings can also have pageantry. There is nothing wrong with this. I love history and tradition. It is an expression of our heritage as Thoracic Surgeons. However, academic surgery and its opinions may be overrepresented. The non-academic surgeon should not be forgotten. Yet it is this surgeon that tacitly approves opinions that may not reflect the realities of his or her practice. Again, disappointing.

Meetings also allow us to see what new technology is out there. Companies set up their booths and put on fancy events. It feels to me like the towns that are hastily built around an encamped army and then follow them around during a military campaign. For full disclosure, I have enjoyed a few good meals on their dime.

So why should we attend meetings? For me, it is the ideas that they give me. They are also an opportunity to renew old friendships. If I can network, this is a bonus, but this is not part of my personality. I would prescribe one scientific meeting per year and one educational meeting, as well. If nothing else, they are an opportunity to get away. And guys and gals, bring your wives and husbands.

* If I have been guilty of such behaviour, I apologize, and I deplore myself for it. I have tried very, very hard not to be a participant in such a spectacle.

My arguments do not apply to the most advanced and specialized centers in the world. These I would consider as quaternary referral institutions. In these centers, the infrastructure exists such that a surgeon may perform 400 cases in one year without the limitations I will outline below. These clinics will have associates, fellows, advanced support staff, and infrastructure that make 400 cases per year for one surgeon safely possible. It also attracts and recruits surgeons and physicians with skill and motivation that are at the upper end of the bell curve. This essay applies to the rest of us.

If a cardiac surgeon performs 400 cases in one year and he/she works 48 weeks in that year (4 weeks off), then they are doing just over 8 cases per week. If an average daily case load is 2 cases per day, then the surgeon is operating 4 days in a week. This leaves one day for an outpatient clinic, continuing medical education, administrative responsibilities, and research (if applicable), assuming a “normal” working day and a 5-day week, excluding on-call duties.

Doing 8 cases per week over time, in my opinion, will lead to chronic physical and mental fatigue. I believe surgeons are trained and encouraged (not overtly) to ignore fatigue and it’s deleterious effects on performance. This “toughness” is rewarded during training by silent approval and the opportunity to do cases. It is later rewarded financially in a fee-for-service environment. This circumstance is further aggravated when on-call duties are taken into account. Some surgeons will operate the next day after having been up the previous night. This acutely fatigued state will aggravate the chronic condition. The negative effects of acute fatigue in the form of sleep deprivation have been clearly documented in medicine. I am unaware of research on the effects of chronic fatigue in medicine, but it is likely to have a similar negative effects. Much like flying an airplane, operating in a cardiac case is a very complex task, where fatigue will compromise the safe conduct of the operation, and potentially lead to an adverse outcome.

Operating is not only a technical act. It is not enough to just know how to operate, but also to know who to operate on, what operation to do, and how to deal with complications as they arise. These are the components of good surgical clinical judgment. Most, if not all, of the decisions about the patient and the operation should be made before one even enters the operating room, including how to deal with potential problems. This can only be done if the surgeon has the time to review thoroughly, completely, and in detail all the available patient data. In addition, the surgeon should have the time to think about the case and develop a plan. The key word here is time. If these intellectual components of surgery are not adhered to with discipline, then quality of care and patient safety are compromised. How can an average surgeon working at an average institution and doing 8 cases per week adequately prepare for a case? I do not believe that they can. To use the flight analogy again, flight planning is as important as the flying.

A surgeon who spends his or her time in the operating room will also not have much time to dedicate to the patients, either pre-operatively or post-operatively. How many patients complain that their surgeon is rushed and does not spend the necessary time to address their concerns? This happens much too often.

Surgeons are not only called upon to operate. They also have other responsibilities related to their profession. These include administrative responsibilities related to their own practice and the institution in which they practice. They also include continuing medical education or maintenance of certification. The latter, in particular, are exceptionally important to the well being of patients. In addition, research and teaching may be components of an academic practice. All of these aspects of a surgical career require time and attention to be done well, or to be done at all. I have directly observed, and experienced as a trainee, the negative effects of a busy surgical practice on research and teaching. I can only surmise the compromises being made to continuing medical education. A professional pilot is expected to have ongoing training and assessments of competency and time is allocated for these endeavours. We owe to our patients and trainees the time to stay current in our discipline. We are also obligated to be academically productive if we are in a University practice.

Most importantly, as human beings, surgeons should also have the time to spend with family and to pursue “hobbies”. This will make us more balanced individuals and in the long run happier people. This can only benefit our patients.

In conclusion, a cardiac surgeon who does 400 cases in one year may be compromising quality of care and patient safety, if they are working in less than a quaternary referral center. What is the ideal number of cases to maintain competency? What is the ideal number of cases to maintain proficiency? These numbers may be an issue for debate. However, it is clear to me that 400 are too many. A surgeon doing this many cases should re-evaluate their practice and perhaps offer younger surgeons more opportunities to attain and maintain competence, while at the same time enhancing the quality of care and safety of patients.

Critics of my views on the adult CV ICU point out that quality care is being delivered by Intensivists. I do not disagree. My principal point is that quality care can also be provided by an appropriately trained Cardiac Surgeon. I believe that there are particular benefits to having a Cardiac Surgeon be an intensivist to his or her patient and these are outlined in the weblog. My point of view seems irreconcilable with some Intensivist's views, but it remains my opinion.

Interestingly, early on in my career I believed that surgeons could not be intensivists to their patients. This was my Canadian perspective. My views have changed given subsequent experiences in the United States. Rightly or wrongly, I hold Mayo and Cleveland as gold standards of excellence. I believe that trying to emulate what is practiced, thought and promoted at these two institutions has merit.

I propose that cardiac surgeons understand cardiovascular physiology better that any intensivist. This understanding is essential for the competent, rational, and pathophysiologic-based care of cardiac surgical patients. Cardiac surgeons alter cardiovascular physiology in the operating room and experience it in a way that is more real than any ICU training or experience can provide. Cardiac surgeons also must be, and are, familiar with cardiovascular pharmacology, and see the effects of drug manipulation on the cardiovascular system first hand in the operating room. Of necessity, cardiac surgeons must also be familiar with hemostasis, ventilatory management, and fluid management, because these are relevant considerations in the operating room. These experiences in the OR translate to the CV ICU and the CV ICU is merely an extension of the operating room.

As the "Most Responsible Physician", the cardiac surgeon is the most motivated to ensure a positive outcome for his patient. If a mortality occurs it is the surgeon, not the intensivist, who is held accountable by Colleges, hospitals, and the patient's family. This results in a level of commitment to the patient that is not equaled by anyone else because, at the end of the day, the surgeon must stand alone to explain the outcome of the patient, good or bad. Others have the option of walking away, and many do.

Cardiac surgeons are also doctors. This means that they will have knowledge of the other body systems. This enables them to care of the whole patient in the CV ICU. However, the cardiac surgeon must realize that he is not expert in all body systems and should consult when appropriate. BUT, it is the responsibility of the surgeon to not blindly accept the advice of another consultant. Any new treatment must make pathophysiologic sense and should be applied taking into account the patient's history and overall condition. The surgeon should be willing to question the opinions of other consultants and is entitled to question the advice given.

The training of a cardiac surgeon should include the constant responsibility for, and primary care of, CV ICU patients so that enough experience is gained to care for these patients and the problems that arise. Operating on and caring for cardiac surgical patients in the ICU (and the ward) should be considered equal aspects of cardiac surgery. It is ALL cardiac surgery. This paradigm I experienced at the Mayo Clinic during my fellowship, where I also truly learned to care for CV ICU patients. I found my Canadian training to be deficient in this regard.

Critics of this model of care will state that cardiac surgeons are not able to be in the operating room and care for patients in the ICU at the same time. There are many practical arrangements that can solve this problem, such as hired intensivists that answer to the surgeons, resident coverage 24/7, and other cardiac surgeons being present in the ICU when their colleagues are operating. The primary surgeon remains responsible for the patient and determines the plan of care along with the details of such plan.

The same critics will argue that surgeons cannot be experts in ICU because they have not been trained as intensivists and they cannot keep up with the ICU literature. Training of a CV Surgeon has been addressed above. I would also add that overall training in ICU is not necessary because CV ICU is a niche where a cardiac surgeon, trained as mentioned, can gain enough experience to be competent at it. Much of the ICU literature does not directly apply to the CV ICU patient. What is more, the relevant ICU and CV ICU advances and controversies will likely be published in cardiac sciences literature, which will be followed by the surgeon. Resources, such as Literature Watch in CTSNet and SESATS can help keep the surgeon abreast of the significant advances in intensive care that apply to cardiac patients.

Intensivists will point out that cardiac surgeons are not capable or trained for a multisystem approach to the ICU patient. The reality is that the majority of cardiac patients have 1 or 2 system problems and most of them will have a brief ICU stay, and they can even be managed by a competent nurse practitioner or physician assistant under the direction of a cardiac surgeon. For the minority of patients that develop multisystem problems, the surgeon, by virtue his training and practice in the ICU, should be able to recognize these problems and request consultations in a timely and appropriate manner. What I must stress again is that the surgeon remains in control of the patient's care and should not blindly follow the advice of other consultants or relinquish to others the care of his patient. The surgeon is ultimately responsible and must ultimately decide what he feels is in the best interest of the patient.

Cardiac surgery is not only surgery, but also cardiac intensive care. They are one in the same. I do not agree with the fractionation of the practice. Sometimes we complain about the manner in which intensivists are managing our patients but we are not willing to re-establish our authority in the CV ICU.

The lack of professionalism (dress, informality/familiarity, impoliteness, disrespect); nurses calling in "sick"; intensivist that think they are the only ones capable of managing post-op cardiac surgical patients; OR delays and summer slow-downs; provincialism; doctors "treating trials" rather than using clinical judgement; entitlement; surgeons abdicating the care of their patients.

(Just to name a few...)

Although I am glad to be in Canada because of the public health care system, I am loath to accept these improprieties. These things, and many others, are not acceptable to me. But how can I change attitudes? How does one engender excellence? How does one create a culture of service to the patient?

Canadians doctors have much to learn from beyond their borders. Pierre Trudeau was one to look beyond Canada to improve it, and for this he was accused of being arrogant.

When I went to my "hometown" to inquire about a job in Cardiac Surgery, it was suggested to me that I return to do a fellowship year there. J'ai reculé. What could they possibly offer me?! After all, I had done my residency there and I was already doing a fellowship at the Mayo Clinic and wanted to stay another year. At that moment, I was not thinking of my parents. However distasteful that proposition was, it was an opportunity to stay on and be close to them in their latter years. I chose to continue at Mayo, closing that door. Obviously, this was the correct professional decision, but not the best personal decision. Now I am faced with the death of Boris Yeltzin, my parents' mortality, and our physical separation. I know they would not criticize me for this decision, but I hope they forgive me for it, because it had everything to do with Cardiac Surgery.

Although, all this may not come to a surprise to many, it says to some that unless the quality of the standard textbooks improves, why should they be purchased if the same information is available on-line. Authors and editors of these tomes should provide us with not only data and information, but also share their knowledge and wisdom. The latter two are sorely lacking in "modern" textbooks.

I would point out that if the supply of donor organs were not limited there would be a dramatic decline in the need for VADs. And yet, there would still be those who would doggedly pursue what has been a holy grail in cardiac surgery: reliable and durable mechanical replacement of the human heart. I do not oppose such a goal, but I must question the application at the present time of what can only be described as mediocre technologies, with significant costs to the patient and society. Should we wait for the development of adequate technology supported by proper governmental funding?

Waiting has been problematic. Decades ago there was a stated US governmental objective to develop a mechanical heart replacement. However, this was not followed by sufficient funding for such a laudable goal. Instead, it has been left to the commercial sector to develop VADs under governmental oversight. These two facts have limited, and perhaps even impaired, the development of a reliable and durable pump. If computers would have evolved at this pace, we would still be using Commodore 64s. Hooray for the free enterprise system.

But why has the money not been put up by wealthy governments, like the US. I don't know. What I do know is that health providers and officials are lamenting the "epidemic" of heart failure in the US and other nations. Perhaps this has not been enough of an incentive to invest. So we are left with the pumps available to us today.

And what does this mean to the patient? It means highly invasive surgical procedures, bleeding, infections, strokes, re-opertions, pump failures, and limited survival measured in months. And all at a significant financial cost to the patient and society. This is of particular relevance to a public health care system such at it is in Canada.

There are no words that can express my gratitude to you, Calvin, for making my time at Mayo bearable and even enjoyable. In the path of life one develops friendships that transcend distance. As I am off to the Other Clinic, I hope ours is one such. I also hope we have the opportunity to work together, for I respect you as a human being and a surgeon. For these two reasons and many others, I give to you the best recommendation I can:

"To Whom It May Concern,

Dr. Wan is my friend and one of the best surgeons I know. I would let him operate on my Mother.

Sincerely,

Luis G. Quinonez"

“Who should we put on the paper?”

“What about Dr. ‘so and so’?”

“No. They are already a full professor. Let’s add Dr. X. He is only an assistant professor.”

The research fellow knows that Dr. X has not contributed to the paper but he is in no position to object.

I do not know how often this happens, however I venture to say that it goes on too often. What did the 4th or 5th author on a surgical paper contribute? In complex studies I would agree that contributions may have been significant. Although, much of what I see published in the major CVT journals is not that complex. In fact, some of the more complicated portions of studies are now the incomprehensible statistics, but I do not know how often the statisticians are authors. Now, if a statistician does not deserve authorship, how is it that a surgeon that simply performed some cases get on the “by-line”.

Editors have made efforts to combat unmerited authorship. Consensus statements have been published; some journals request that authors state what they have contributed, specifically. Nevertheless, individuals still become authors with minimal or no effort on their part.

I will forget for a moment the reprehensible attitudes and behaviour that allow this to happen. What I will propose is a simple scoring system to evaluate the publications of an individual.

1. 2 points are given for 1st authorship; 1 point for 2nd authorship; and ½ of a point 3rd authorship.
2. Add 3 points for an RCT; 2 points for a comparative retrospective series or a large registry study; 1 point for a case series; and ½ for systematic reviews.
3. Multiply the points earned in 1 and 2 by the impact factor of the journal in which the article is published.

Case reports are not included. If a teaching point is to be made by a case report or image, this should be done for its own sake and the benefit of others.

The scoring system is simple, and arguably simplistic. It does not take into consideration the variability in the quality of RCTs, for example. Yet it is an attempt to fairly evaluate the quality of, and the contribution to, the publications by an author. By limiting the credit to only the first 3 authors, I am trying to eliminate those authors that may not have contributed significantly or at all. This latter point may be contentious, but it is an argument we still need to have.

1. I have accepted the fact that I have to do more training and I will.

2. I continue to believe in the Canadian public health care system and I want to work in Canada.

3. There is value and worth in what I have accomplished thusfar in surgery and I can be proud.

4. I have the skill, knowledge, judgement, and confidence to be a consultant.

5. I can carry myself as if I were a consultant.

The biggest challenge I have faced, when reading and hearing rejection after rejection, has been to maintain a sense of self-worth as a surgeon. I have heard several times that my fellowship at Mayo Clinic is of no added value. Trends will come and go, but a solid training will last an entire career and will transcend all trends. Those who follow the trends in cardiac surgery are more interested in appearances than in the best quality of care for patients.

So it is with all this in mind that I carry on. Things will work out and my time will come. This I have to believe to be able to tolerate more years of uncertainty, debt, and subordination.

Prior to completing my residency in Cardiac Surgery, I took some time off and was in private practice in General Thoracic Surgery (St. Joseph's Hospital, Hamilton, Ontario, Canada) for 9 months. My views on the subject are quite coloured by this experience. What I am seeing at the Mayo also influences my opinions on the subject.

I believe that a fee-for-service system has a negative influence on the practice of surgery. The pressures of volume based remuneration lead surgeons to see more patients and do more procedures. In this model of practice, the patient is the one who suffers. Less time is spent with patients and families, whether on rounds or in the office, due to the time pressures inherent in such a system. I believe that part of the reason our profession has been devalued in the eyes of the public is that we do not spend enough time with our patients. When I was in practice, the cynicism of some made me cringe. I would book one hour for all new consultations for lung cancer. Some of my colleagues could not believe that I would spend so much time. They told me not to worry, that I would get faster! To me, this was not an issue of speed!!!

I am not suggesting that procedures are performed unnecessarily or hastily. This would be unethical. However, I do believe that procedural indications and performance are modified in such a way as to benefit the surgeon's purse. Two examples: During a CABG the intra-op TEE reveals a small PFO. Closure of the PFO is not unsafe for the patient and is easy to do. One can argue you are already there so why not? There is a theoretical benefit. However, PFO is a normal finding in an otherwise healthy part of the adult population, so you could leave it alone. If you were paid extra for the closure, what would you do if you were not placing the patient in any danger.

The second example is a drainage of an empyema as an add-on case. There is a premium for cases starting after 6 pm in Ontario. Your case is ready to go at 5:30 pm. Do you and your anesthetist drag your feet to start at 6 pm? It does not place the patient in any danger and it is easily done. I have lived this situation, and I can tell you that when you are starting out in practice and there are bills to pay....This is reality in a fee-for-service system.

There are numerous examples that can be given: some I have experienced first-hand; others I have seen and others I have been told (sometimes as words of friendly advice to a junior staff from those who know the system better). This goes on to a greater or lesser degree on a daily basis.

The other issue is that of dignity. I have seen so many surgeons 'nickel and diming'. They would chase after every cent they believed the system owed them for their sevices. I found this to be a pathetic spectacle. However, the system was set up to reward them if they did this. I have nothing but contempt for this behaviour and for the system that allows and encourages it to occur.

What about a salary-based system? I believe that surgeons would spend more time with their patients and families. It would encourage the performance of procedures for purely medical reasons, without the corrupting effect of volume-based remuneration. However, I think this system must come with a commitment from the surgeon to provide the best possible care, whatever the circumstances.

The danger of this system is the apathy that can develop when income is assured. For example, delays in surgery because there is no pressure to perform operations, which increases waiting lists. Surgeons need to provide a good service to society, and therefore must increase their volume of work as the need arises, even if their income is the same. Another potential issue is the performance of operations during "off-hours". There is no incentive to do this with a salary. Surgery needs to be done when it is needed by the patient, and not at the convenience of the surgeon.

In a salary-based system, the surgeon must rely more on his/her desire to treat patients well. The intrinsic value of excellence in patient care is paramount. Take the example of some cardiac surgeons at Mayo Clinic. What drives them to do the number of complex and difficult cases the do? However many, and however difficult, patients they see, they will be paid the same. I believe that they is internally driven by the need for excellence.

I awknowledge that this system is not perfect. However, I am convinced that it is the most beneficial to our patients. In the long-term, it will select out young doctors that will become surgeons who's drive is less about money and more about excellence in patient care.

A culture of service is reflected in the mission statement of the institution. But it goes beyond this. The founders of the Clinic set the tone for it's future: "The needs of the patient come first" or "The interest of the patient is the only interest to be considered". However, it goes even further that words. What struck me most about the Clinic is that these words are paractised on a daily basis by all levels of employees of the clinic. Everyone is pleasant; everyone is helpful. I felt that there was truly a "culture" of service. It has a feel to it; it is in the corridors of the hospital and in the walls of the clinics. Patients tell you about it, as they express their pleasant surprise about how "different" things are here.

To be fair, much of this stems from the profit-based medical practise in the USA. A culture of service is a useful business model to attract and retain patients. It works in the hospitality industry and applies well to medicine-for-profit. However, I think that this should not detract form the benefits it provides the patient and their families. I believe that we should try to emmulate this "culture of service" in our Canadian health care system, despite our resource limitations.

Resource limitation is a reality in Canadian medical practise. It leads to healthcare worker fatigue and burnout. This is perhaps one explanation for the lack of culture of service, which I have witnessed. However, there are attitudes and behaviours that are not resource dependent. We can all be more polite and less rude to our patients and to each other. Pages and phone calls can be answered more promptly. Phrases such as “how may I help you” or “can I do something for you” should be said more often. Regardless of who we are, we can answer questions or find someone who can. Pain should be treated more expeditiously (there is no shortage of morphine). Call lights should not go unanswered. And it all comes from the top, down. If a consultant is the one who first goes to help a family member waiting at the nursing station, quickly others will follow.

Our attitude should change from one of “this is not my problem” to “how can we help this patient”. Nurses should say less “I am not looking after that patient” and more “let me find someone who can help you”. Doctors should say less “this is not a problem in my specialty” and hang-up the phone. They should say more “I think this is not a problem in my field, but have you considered…Maybe you should consult…What about trying...”. Our frame of mind should not be one of relief when a patient does not have to be admitted to our service, but one of concern that the patient have a proper diagnosis and get the appropriate care.

We have also shifted our minds into cost savings rather than patient care. I believe this has had the largest negative impact on the potential development of a culture of service in the Canadian healthcare. There are glaring situations that typify this attitude. For example, there is the request for radiological investigations at night, when resistance is encountered and questions as to whether or not the patient truly needs the investigation. The underlying attitude here is the protection of a microbudget, rather than the best interest of the patient. What is worse is that the determination of need is being made by someone over the phone who has not even assessed the patient. Another example is the guarding of intensive care unit beds. Whether or not a patient gets admitted to an intensive care unit should be criterion-based and not on arbitrary judgments that are influenced by bed availability. Again, the interests of the patient should be the only interest considered and the system must adjust accordingly. In essence, a culture of service should take into account that the patient takes priority over the existing budget.

By no means am I suggesting that resources should be over-extended. Judgments about the true need for an investigation or an admission to an ICU bed should be made at the consultant level given the limited resources that exist. These decisions should not be left to residents, nurses, or administrators. And if a consultant is going to withhold a resource that has been requested by another consultant, it is a reasonable expectation that they see the patient and the reason for the denial be documented by them in the clinical record.

How does one reconcile a culture of service with the limited resources of the Canadian health care system? American-style for-profit health care is not the answer. It can be done within the existing structure by accepting the FACT that resources ARE limited. We, as consultants, can change our attitudes and behaviours to reflect our belief that the needs of the patient and their families do come first. Others will follow. If the quality of the care you deliver is in direct relationship to the amount of government funding, you should not be a doctor. Furthermore, the “triage” of resources is too important to be left to anyone less than a consultant. As consultants, we should be at the patient’s bedside making the critical determinations about their care. Patients and their families should see and know that we are in charge of their wellbeing. It is here that the culture of service begins.

After two years at the Mayo, I will not say that I am an aortic surgeon or a transplant surgeon or an arrhythmia surgeon or anything else. However, I would have seen enough of many kinds of cases to perform some of them competently. For example, I will be able to participate in a transplant program, but I would not venture into starting one; I would be comfortable tackling cut-and-sew mazes after some time in practice, but I would not call myself an arrhythmia surgeon; I would feel comfortable dealing with a primum atrial septal defect in an adult, but I am not a congenital surgeon. And if I choose to focus my practice in an area, I have the skills to do this. For example, I have performed some mitral valve repairs during my residency and as a fellow I have performed all the components of a P2 resection. But, more importantly, as a trained surgeon, I have seen all sorts of complex mitral valve repairs and, in time, I will tackle these cases. Yet I would not say that I did a fellowship in mitral valve repair.

I am not trying to be arrogant or cavalier. I am an average cardiac surgeon and I am aware of my limits (one also needs to be cautious and conservative during the first years of practice). I just want to explain, in part, the comprehensive training one gets at a place like Mayo. For those who have never experienced this, they will not understand how, and will have difficulty accepting that, this is possible. Nevertheless, many surgeons who have done these sorts of fellowships are the 'go-to' surgeons at institutions because they are willing to take on difficult and complex cases. They can draw upon a significant experience obtained during their fellowships and translate it to a variety of situations. Yet this type of training does not seem to be valued by some and is not what others think to be an acceptable and marketable fellowship.

What is sexy today is a fellowship in robotics, heart failure, minimally invasive, arrhythmia, or aortic stents, to name some. The assumption here is that basic skills have been obtained during residency and no further refinement is necessary or desired. The only skills that are valued are new and innovative ones, whatever the flavour of the day. Proponents of these fellowships will argue that by performing these 'advanced' techniques one can translate what is learned towards what is 'basic'. In addition, there is, in fact, exposure to other kinds of cases during these fellowships, making them not so narrow. Both are very valid arguments.

I believe that both types of training are valuable components for the development of an academically-minded division of cardiac surgery. And, importantly, a division head must have a clear vision in his/her mind of where he/she wants to take the division in order to develop a rational recruitment strategy. However, I believe that one cannot build a division with subspecialists only. In fact, a smaller division may need to concentrate only on the excellent delivery of basic general cardiac surgical care before even considering branching out into subspecialization. Subspecialization must rest on the shoulders of excellent 'basic' care.

By arguing the above, I am not trying to be self-serving. It is no secret that I am also looking for a position as a cardiac surgeon in Canada. What disturbs me is the impression given to me by some that a fellowship without subspecialization is less valuable or important. Subspecialization is nice, but solid excellent basic care is more important. The reality is that many, if not most surgeons, will not get to use their subspecialty skills. I know of surgeons who have done fellowships in transplant, pediatrics, robotics and do not have the opportunity to use these skills.

The reality of Canadian practise is that not every institution can be a transplant, robotic or pediatric centre, etc. It is an issue of patient volume and resources. Even some academic institutions must accept this reality. We should not view this as a limitation. Our reaction should be to change our focus to those things that we can do well and with excellent results, and then build upon that.

I have been very tired lately. I have been working long and stressful hours. However, I am trying very hard to spend time listening to my patients: On rounds each day, I shake their hand and sit at a chair or on the bed, as is feasible. These actions prevent me from rushing. I am trying to be a better doctor.

When I was a medical student doing a rotation in Obstetrics, the hours were long and I was exhausted. I complained to you about having to get up in the middle of the night and do deliveries. I spoke about how I cared little about seeing another human being brought into the world. The details of the conversation escape me now. Some days later you gave me a hand written note. It is somewhere in my personal things and I wish I had it with me now. Nevertheless, the message was: That to me it was just another delivery, but to the parents of this baby, this was the most important moment of their lives; I should not forget this when doing "just another delivery".

I believe that this advice applies to all patients. To me, it is just another CABG or another mitral valve repair or another whatever. To the patient, it is the event of a lifetime. I am trying to follow your advice. I am trying to be a better doctor.

Thank-you, Dad. I love you,

Your son