In Memoriam of Thoracic Surgery

Nelson Ancalmo

To the Editor:

The field of thoracic surgery has undergone some incredible changes. Just a couple of years into my retirement, I have come to realize how fortunate I was to practice during the golden age of the specialty that I embraced during my entire adult life. At the same time, I am deeply concerned by the image of the new generation of thoracic surgeons.

When I review the fantastic accomplishments of thoracic surgery for the past 50 years and witness the current state of our practice, a very disturbing picture comes to life. The list of procedures that are no longer under our control is frightening, and the changes to the ones that we still do are significant.

To start with, the field of thoracic surgery is divided: pulmonary, esophageal, and other thoracic procedures are in the hands of general thoracic surgeons, and cardiac operations are in the domain of cardiac surgeons. Vascular interventions now are the property of vascular surgeons, and both cardiologists and radiologists are competing to do the same procedures that in the past were performed by thoracic surgeons.

Everything that I studied so hard for so many years is gone. Yes, gone and replaced by procedures that are performed using needles, catheters, fluoroscopy, stents, endografts, etc. Some are great advances, I must admit that, but whether we like it or not, these changes are not surgery, at least not the surgery I remember.

I grew up during that golden age of thoracic surgery that I now reminisce over. In those days, we did our own bronchoscopies and then pulmonary resections; our own upper endoscopies and esophageal surgery; coronary bypasses, lots of them, even for single vessel lesions; all kinds of valves, repairs and replacements; and also congenital heart procedures. We did peripheral vascular surgery, from neck to toes, and all those cases were mixed usually within a single week of work.

There were no thoracoscopies or minimally invasive surgery, no balloons and stents, and robotic surgery was not even in the science fiction stories. Small aneurysms were followed with periodic ultrasounds and repaired when considered to be enlarging or too big, and the list goes on and on.

I am not practicing medicine anymore; I am fully retired. Retired after an entire life devoted to the specialty that I fell in love with during my surgical training. I still remember my days at the Ochsner Clinic in New Orleans, mesmerized by the expertise and knowledge of the 2 surgeons who trained me, Dr. John Ochsner and Dr. Noel Mills.

Seven years of relentless learning, practicing, watching, and doing until the hands and the mind began to work as one. Days and nights of operating, making rounds, attending lectures; days and nights full of disappointments, frustrations, depressions away from my family, and trying to survive with one goal in my mind—to become a thoracic surgeon. That was all I wanted to be.

Now, we are told that we have to start all over again, not as surgeons, but as something totally different. What disturbs me more than anything is the precarious situation that young and future thoracic surgeons are going to face.

The young ones will have to learn new disciplines. They will be required to be trained in invasive procedures and to begin competing with cardiologists and radiologists and vascular surgeons. Some may have to spend time learning pulmonary and esophageal surgery and also peripheral vascular surgery.

All those were our fields; we gave them away resting on our laurels because we were too busy doing coronary bypasses. Now we need to take them back if we want to survive in the highly competitive world of tomorrow.

The future thoracic surgeons, those still in medical school, are a different story. They will have to be told what to expect of the specialty. They will need to be trained in a different way, as clinicians, radiologists, and surgeons, or as the newest rapidly evolving specialty, surgical interventionist.

Obviously, 7 years of surgical training are a waste of time for somebody who will only perform small openings; work with needles and catheters; or, even worse, perform a surgical procedure looking at a computer screen while the patient rests in the next room. Yes, the curriculum will have to be very different.

The golden days are gone. In a way, we are responsible for losing so many fields of our specialty. We are also responsible for losing that privileged position that we used to occupy in the medical profession. I am proud that I will be called a thoracic surgeon until the last day of my life. I don't need any other name; that one says it all.

It means that I spent a minimum of 7 years of surgical training; it means that I am proficient in all types of procedures involving the thoracic cavity and its contents; and it means that I am also a general surgeon. With mixed feelings I am happy to be retired; I don't think I would like to be called a surgical interventionist.