Choosing the "right" fellowship for Canadian cardiac surgery

Whenever I tell someone that I am doing a fellowship in cardiac surgery at the Mayo Clinic the first thing they ask is what is my area of subspecialization. It is difficult to answer this because at Mayo there is no such fellowship. The training is in advanced adult cardiac surgery, which means that you participate in all aspects of cardiac surgery. This includes, for example, valve repair, aortic and aortic root surgery, atrial fibrillation surgery, adult congenital surgery, transplantation and assist devices, heart failure surgery, and so on; Not to mention the high volume of re-operative cases and the surgical treatment of unusual conditions such as HOCM, constrictive pericarditis, Ebstein's anomalies, carcinoid heart disease, chronic pulmonary emboli, and others. This is in addition to the usual CABGs, valve replacements, endocarditis, dissections, etc...Yet this amazing experience is not enough for some surgeons and even some cardiologists, who are wowed by new techniques and impressed by those that call themselves minimally invasive surgeons or off-pump surgeons or whatever.

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.