Commentary: You can't cheat on exposure.

David L. Joyce, MD, MBA, FACS

Beyond the enhancement of technical and cognitive skills, cardiac surgical simulation may provide an opportunity to increase exposure to the specialty.

See Article page 179.

In the growing body of research pertaining to simulation in cardiac surgery, the focus has traditionally been on developing tools that could augment the limited educational opportunities that exist in the clinical realm.1, 2, 3 In this important study by Rabenstein and colleagues, a new paradigm has been introduced whereby the value proposition for cardiac surgical simulation extends to the recruitment of new trainees.

One of the most important points that is raised in this manuscript involves the lack of exposure to cardiac surgical experiences that is available to medical students and residents in the majority of training programs. In light of this reality, the happy accident in which an individual discovers an interest in cardiac surgery after nearly a decade of well-baby visits, hernia repairs, and emergency department rotations seems highly improbable. Of course, having a passion for the specialty is only half of the equation. Skill is also needed.

Simulation offers a potential solution to both of these challenges, but for this strategy to work there must be a level of realism that can both inspire and prepare the trainee for the challenges and opportunities that await. The authors' implementation of team training should be congratulated, as these types of interactions provide a glimpse into both the rewards and the difficulties that distinguish heart surgery from other types of procedures. The authors build on the previously established simulation tools for teaching coronary anastomosis, aortic valve replacement, and mitral valve repair, but in the end each of these models represents only a small fragment of the various components that contribute to a successful outcome and are each limited in the degree of realism that they offer. The proliferation of computer algorithms that can routinely outperform chess Grand Masters and golf simulators that can provide quantitative feedback beyond anything accessible on the driving range suggest that technology will prevail in the development of high-fidelity cardiac surgery simulators. In the meantime, the integration of clinical decision-making and technical skill that comes from simulating aspects of cardiac surgery in the context of a live patient (also known as “General Surgery Residency Training”) continues to serve as the standard by which novel approaches are measured. For this reason, the specialty should not discount the importance of recruiting from this applicant pool, and the strategy outlined in this original manuscript offers a promising new strategy.

Future studies should expand on evaluating the impact of such interventions on conversion rates (previously undifferentiated general surgery residents who opted to pursue cardiothoracic after exposure through a simulation experience). Given the novelty of this type of approach, comparisons against programs that lack any formal exposure to cardiothoracic as part of the curriculum could yield further insights on the benefits of such strategies.