We have all heard of the imminent death of cardiothoracic surgery as a medical specialty. The field had its meteoric rise and now is on the rapid descent. Adult cardiac surgery is being taken over by Cardiology, adult thoracic surgery is really not a sustaining specialty unto itself, and congenital heart surgery should only be centralized in a few small centers. Like many rumors there may be some half-truths in those assertions but in the current reality of modern medicine it is highly unlikely that cardiothoracic surgery will flounder for long or fade away completely.

If one steps back and tries to look at cardiothoracic surgery in the broadest historical perspective, the specialty is still in its infancy... still going through its growth spurt... still looking for the sustaining equilibrium. Since the first durable thoracic operative procedures in the 1930s, and the first open cardiac procedures in the 1950s, we have only been around as a specialty for a little over 50 years. We were initially a small, highly focused, very professional group of surgeons exploring the boundaries of science, surgery, research, and ethics; we were mostly focused on lung cancer and congenital heart disease. Our specialty was then subsequently fueled by a new, remarkable technology (cardiopulmonary bypass) which allowed reconstructive work within and on the heart in an essentially bloodless, motionless field. This new technology occurred at a time when first, compliance issues and human research oversight was minimal compared to current standards, and secondly, a huge untapped population of patients with atherosclerotic coronary artery disease was discovered. Coronary bypass surgery evolved and fostered an explosive growth and also allowed us to attract the best and brightest of young surgical residents. The downside of this remarkable growth was a change in perception of our specialty as a "profession" into one simply driven by business and market forces (a "commodity"). We maintained our security for over two decades until our equanimity was shaken by new, less invasive, endovascular technology that we no longer controlled: non-surgical approaches to coronary disease, some congenital disease, and with the potential to even threaten our exclusive bastion, valvular heart disease. The pendulum swung away and change occurred.

I believe anyone in my position as a thoracic surgical program director, someone involved in thoracic education, academics and clinical care, would not want to be perceived as either the "grim reaper" or the "pied piper" when it comes to looking at the future. None of us have crystal balls and our perceptions of the future are very much predicated on our past experiences. However, in my humble opinion, this specialty is neither dead, nor dying. It is simply adapting to disruptive challenges; it is facing change, it is re-engineering. Like any other successful profession or business, it is how we make that adaptation to change which will determine our future. There is a long list of things we could or must do as a specialty to secure our future that almost anyone in cardiothoracic surgery can come up with. One only has to look at the presidential addresses from any of the four major thoracic surgical societies for the last 5 years to develop such a list. There are some themes that do reoccur: we must partner with industry and embrace new technology, we must have better control of imaging, we must participate in solid scientific prospective clinical trials, we must maintain a basic scientific foundation, we must work hard(er) to recruit the best and the brightest to our specialties, we must understand and practice the art of mentorship, we must retrain, we must be proactive and bottom line, we must be patient obtaining real data, we must face change head-on, and we must constructively adapt to disruptive challenges.

Already we are seeing some of that adaptation. The STS cardiothoracic database is solid, extensively used and has become a benchmark for specialty / professional outcomes analysis. We have initiated our own NIH sponsored prospective surgical clinical trials (NETT, REMATCH, STITCH) which have been published and have established well accepted clinical guidelines and remuneration schemes. We are involved as surgeons in the development of new valve, ventricular assist, lung volume reduction, and other technology (3-F Therapeutics, Thoratec, Spiration). We have dynamic leadership in our major surgical societies that are involved in all aspects of the clinical, academic, educational, administrative, and political arenas. We are also seeing the unrealistic expectations and favorable early published results of percutaneous technologies coming back down to statistical reality. The almost biologically unbelievable clinical results with drug eluting stents might not be as wonderful as initially reported, and in fact, may be even more dangerous long term than coronary bypass surgery. Hopefully such emerging data will allow better comparison with outstanding long term historical surgical controls. The pendulum is swinging again... and now back towards us.

Cardiothoracic surgery is special. We do procedures and have responsibility that no other physicians are given the opportunity to have, we take care of some of the sickest patients but we effect some of the most dramatic favorable outcomes. We truly make differences in peoples lives, and the members of this exclusive "fraternity" are remarkable people and enduring friends. Cardiothoracic surgeons are leaders and they will assure a bright and enduring future for this specialty.

Edward D. Verrier M.D.