Re: Lange R, Hoerer J, Schreiber C. What are the obstacles to training in surgery for congenital heart disease in Germany? Thorac Cardiovasc Surg 2013;61:273–277
01 April 2014 (online)
The authors primarily deal with two aspects of the impact of center volume in congenital heart surgery in Germany: first the impact on training and second the impact on quality of outcome.
The authors state that both—training and quality—cannot be achieved in low-volume centers because of stringent connection to center volume. The authors prove this with findings in other European countries. However, these are not transferable to Germany for reasons explained later. In addition, results of the comprehensive Aristotle score have demonstrated excellent quality of outcome in some low-volume centers. The authors also state that low-volume centers are run by a “soloist” and do not provide 24-hour backup 365 days a year. Where are the data for this?
A second aspect of the article points out the problem that congenital heart procedures are not officially counting for the board certification. One should be cautious about diminishing the basic requirements of heart surgery by specializing very early. Any congenital heart surgeon should have insight into surgery for acquired heart disease and be able to perform the standard procedures, particularly in view of the increasing number of adult patients with congenital heart disease. There are increasing problems with surgeons not having a broad basic education, which were enhanced after reducing requirements in general surgery for heart surgeons. The board certificate for heart surgery should remain the basis, and specialization should be done on top of it.
Congenital heart surgery is considered the most difficult surgery of all specialties requiring technically, mentally, and intellectually the best to have the optimal outcome. The responsibility is extremely high because surgery has lifelong impact on quality of life of the patients and their families. The German system is characterized by a hierarchical structure with a head surgeon with “his/her” team. Consecutively, any surgeon having a certain experience tries to reach a head surgeon's position. Thus, it is unlikely that a center has a complete team of well-experienced surgeons. This raises the question of who is doing the 400 cases a year in the high-volume centers.
The dispersal across many centers in Germany does not necessarily cause a lack in training. In contrast, a “soloist” needs to train a team to fulfill the legal requirements. These trainers are not going to “forget” their own skills. One does not lose skills by training others because the most experienced surgeons will always be the ones who do the most difficult procedures.
The quality of outcome of congenital heart surgery primarily depends on the surgeons. Surgeons' performances do not just differ in technical skills but also in patient selection and surgical strategies, that is, short-sighted surgical procedures may be easier but may end in unnecessary palliations and an increased overall strain for the patient. Thus, high-quality congenital heart surgery is also a question of dedication, personality, and enthusiasm for the patient. Going into extremes, this dedication reduces the surgeon's quality of life. In the same manner, training is a question of personality, enthusiasm, and dedication for the trainee. Training is even more demanding than operating, so it is additionally decreasing the surgeon's quality of life. There is neither an obligation nor a reward for this.
In summary, training in congenital heart surgery depends on the personality of the trainer.
This also applies to adult cardiac surgery. However, here many procedures are standardized and the variability of surgical strategies is much smaller. Another difference is that in congenital heart surgery, the procedures are often technically and mentally demanding. A congenital heart surgeon has the hardest surgical task being additionally under the mental pressure of having a child in his hands. Training these procedures in the operating room is an enhancement of this strain. Often, it is almost impossible to control the fine movements of the trainee. Also, intracardiac procedures are difficult to assist, as the view is limited.
In Germany, we do have a general problem of training in heart surgery: Neither many experienced adult heart surgeons nor congenital heart surgeons are enthusiastic about it. Why was there only one nomination in Germany for the Da Vinci training award in 2011, when it was introduced? There is obviously something to improve in Germany, not in volume and size, but in the minds of heart surgeons in general.
Where are we supposed to find the extremely good pediatric surgeons who are willing to train, to put personal power in something, which does not “pay” directly? Where is the rationale to argue that these people are found in high-volume and not in low-volume centers? They will very likely be found in a center of any size. In reality, there are very few of them. They have strong mentorship with their trainees for a lifetime so that one should be able to identify them and analyze their characteristics.
In conclusion, caution should be given regarding the equation: “Volume = Quality = Training” for congenital heart surgery in Germany.