Building a Successful

Career: Advice from

Leaders in Thoracic

Surgery

Sean C. Grondin, MD, MPH

I have been an attending thoracic surgeon for more

than 10 years and, like many surgeons, work hard

to provide exemplary clinical care, to be a good

mentor and teacher, and to publish valuable

research contributions. I have been fortunate to

have had mentors who have guided me through

my surgical training and early years of practice,

and a wife and children who help me to maintain

a delicate work-life balance. At midcareer, I realize

how much I have learned from and been influenced

by the experience and guidance of other surgeons.

With this in mind, an outstanding group of surgeons

(Box 1) were selected to each write a short

summary of what they deem to be key elements

for developing a successful thoracic surgical

career. These unique and informed perspectives

offer many insights that will provide useful lessons

to others in our field.

MARK S. ALLEN, MD

A career in thoracic surgery is rewarding but also

demanding, requiring substantial commitment

and serious dedication. Although thoracic sur-

geons make a major difference in patients’ lives,

they may also cause harm by choosing overly

aggressive operations, making a technical error,

or failing to operate at the right time. Developing

a successful thoracic surgery career is about mini-

mizing the harm and maximizing the benefit to

patients and their families. My section of this

article gives a brief introduction of the basics of

developing a career in this fascinating profession.

The foundation of any career, and especially one

in thoracic surgery where the stakes are so high, is

in obtaining the proper training. Most of the oper-

ations and techniques I use today in practice

were not invented when I was in training; therefore,

education should provide a platform on which to

learn. Students should seek to obtain a solid foun-

dation in anatomy, physiology, pathology, and

basic patient care. This foundation enables sur-

geons to adapt and shape their skills as new tech-

nologies arise to fit the needs of the patient and

provide a solid understanding of the reasons why

certain operations are chosen. Without a solid,

basic fund of knowledge, a surgeon will just pick

up whatever comes along and give it a try, floun-

dering in a sea of uncertainty, with no clear under-

standing of why some patients do well and others

do not. Knowledge is required to objectively eval-

uate a new technique or procedure to have some

reasonable hypothesis that the operation will be

of benefit to the patient. Acquisition of knowledge

is never complete. Learning must continue after

residency, sometimes even at a faster rate, for

thoracic surgery is advancing quickly. The suc-

cessful thoracic surgeon stays current and uses

this new knowledge for the patients’ advantage.

After initial, fundamental knowledge is obtained,

a surgeon must establish a practice. Today, this

almost always means joining a group practice.

The former chair of the department of surgery at

Massachusetts General Hospital, Dr G.W. Austen,

gave me some advice when I was a resident that

has proved to be useful. He noted that 3 factors

Division of Thoracic Surgery, Department of Surgery, Foothills Medical Centre, University of Calgary, 1403 29th

Street NW, Room G 33 D, Calgary, Alberta T2N 2T9, Canada

E-mail address: [email protected]

KEYWORDS

Career Success Advice Thoracic Surgery

Thorac Surg Clin 21 (2011) 395–415

doi:10.1016/j.thorsurg.2011.04.008

1547-4127/11/$ – see front matter © 2011 Elsevier Inc. All rights reserved.

thoracic.theclinics.com

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are important when choosing a practice to join. The

first is the individual partners themselves. These

are the people you will have to interact with on

a daily basis. It is vital that you can work well with

these people for, if not, every day is going to be

a challenge. Developing a solid working relation-

ship with your partners is of primary importance.

They should be trustworthy, honest, reliable, and

excellent surgeons. The second feature is the

department in which you are going to work. Inter-

action with the department is not as important as

with your partners, but the department will still

influence you, although less frequently than your

partners. The department should be supportive of

what you need and want to accomplish; not

controlling, but encouraging your career progress.

The final characteristic to consider when choosing

a practice is the institution you work in or are affili-

ated with. This entity should have a good reputa-

tion both locally and nationally. The goals and

objectives of the institution should be aligned

with yours. The institution you work in will charac-

terize you before anyone meets you, and will affect

your practice, so choose carefully.

The final aspect of developing a successful

thoracic practice is personal development. Medi-

cine can be an all-absorbing profession and the

needs of patients are limitless. Many physicians

have lives that are consumed with medicine, and

they turn into one-dimensional people, concerned

only for the welfare of their patients, ignoring

personal and family responsibilities, only to burn

out after several years. Successful thoracic

surgeons have other interests and are able to

successfully balance work with their personal life,

making time for their family, taking time off for their

own interests and hobbies. This balance allows

them time to unwind and come back to work with

a fresh outlook, often with new ideas, always with

a renewed energy level. Thoracic surgery is a phys-

ical activity, often requiring long stretches of intense

concentration in addition to standing, bending, and

pulling. Keeping in shape by exercising, and

controlling your weight by eating properly, are also

important characteristics of a successful thoracic

surgeon. It does little good to train for 30 years,

learning the craft of thoracic surgery, and then not

be able to perform in the operating room because

of poor fitness. Staying fit gives time to develop

experience as a surgeon, for, as everyone knows,

experienced surgeons are good surgeons, and expe-

rience takes time to develop.

Being a thoracic surgeon is one of the best jobs

in the world. Compensation is good, operating is

enjoyable, patients are challenging, and it provides

the opportunity to help people live longer, more

Box 1

Contributors to this article

Dr Mark Allen, MD

Mayo Foundation, Rochester, MN

Dr Robert Cerfolio

University of Alabama, Birmingham, AB

Dr Gail Darling

University of Toronto, Toronto, ON

Dr Jean Deslauriers

Université de Laval, Québec City, PQ

Dr André Duranceau

Université de Montréal, Montréal, PQ

Dr Mark Ferguson

The University of Chicago, Chicago, IL

Dr Richard Finley

University of British Columbia, Vancouver, BC

Dr Michael Johnston

Dalhousie University, Halifax, NS

Dr Mark Krasna

St Joseph Cancer Institute, Towson, MD

Dr Toni Lerut

Katholieke Universiteit Leuven, Leuven, Belgium

Dr James Luketich

University of Pittsburgh, Pittsburgh, PA

Dr Douglas Mathisen

Harvard University, Boston, MA

Dr Robert McKenna

Cedars Sinai Hospital, Los Angeles, CA

Dr Griffith Pearson

University of Toronto, Toronto, ON

Dr Carolyn Reed

Medical University of South Carolina, Charleston, SC

Dr Jack Roth

The University of Texas MD Anderson Cancer Center, Houston, TX

Dr Valerie Rusch

Memorial Sloan-Kettering Cancer Center, New York, NY

Dr David Sugarbaker

Harvard University, Boston, MA

Dr Manoel Ximenes

Planalto Central School of Medicine, Brasilia, DF, Brazil

Dr Anthony P.C. Yim

The Chinese University of Hong Kong, Hong Kong SAR, China

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396

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productive lives. It is hoped that these suggestions

and comments will help develop a few surgeons

into the leaders of tomorrow.

ROBERT JAMES CERFOLIO, MD

To write about what it takes to build a successful

career in cardiothoracic surgery the word success

must first be defined. The problem is that this defi-

nition is controversial and debatable. What does it

really mean to be successful? Is it how much

money you make, how happy you are, how many

operations you perform each year, how fast you

do them, how little blood your patients lose, how

well your patients do, how you are viewed by

your trainees or staff, and so forth? For most, it

is a combination of these factors and many others.

Webster’s dictionary defines success as “a favor-

able or desired outcome – the attainment of

wealth, favor or eminence.” I find this definition

to be shortsighted and perfunctory.

Because the definition or state of success is not

agreed on, the characteristics required to get there

are not be definable or agreed on either. Given

these caveats, I offer my opinion (and that is all

anyone can offer on this subject) of what I believe

are important attributes that lead to a successful

career in surgery, and list attributes that are unique

and different from those discussed by the other

contributors to this article.

Although this article is specific to a career in

cardiothoracic surgery, many of the attributes

that any of us list could probably be applicable

to success in any career. I am sure that every

author will mention hard work, dedication, com-

mitment, passion, compassion, honesty, knowl-

edge, intellect, timing, a supportive academic

environment, and so forth; however, in order for

my essay to be different and perhaps more helpful

to you, I offer some attributes that may be more

specific for a surgeon to be successful compared

with a lawyer or business person. The first word

that comes to mind, and one that is probably

unsuspected, is athleticism.

I define athleticism as the ability to perform a fine

motor skill again and again under high pressure

while working together with other team members

and while acting as a team leader. Surgery is the

ultimate team sport and a cardiothoracic surgeon

cannot be successful if he or she is not good in

the operating room. So, besides all of the obvious

characteristics that are required for anyone to be

successful in most any aspect of life (eg,

outstanding education and training, good men-

tors, industriousness, some element of luck, family

support), a successful thoracic surgeon has to be

adroit in the operating room. This ability entails

working well with others, being respected by the

other team members, and controlling one’s nerves

and emotions under pressure. This quality starts

long before residency and maybe even before

kindergarten; it may even be partially genetically

programmed. Either way, it is a critical aspect of

being successful.

Another attribute that my esteemed coauthors

may not mention is availability. I know many

talented surgeons who are skilled technical

surgeons and leaders with excellent people skills

but who are not successful. This failure is because

many lack the organizational skills to be available

and reachable. The best way to build a busy and

successful surgical practice is to always be avail-

able when a medical doctor needs your services.

Perhaps more than ability or affability, availability

is a critical aspect of a successful career in surgery.

Stamina is another quality that is often over-

looked. Our training is long; most of us do not start

our practices until we are in our early 30s. I have

seen many surgeons who become burned out by

45 to 50 years of age. They lack the passion to

keep going; they lack the emotional and physical

toughness and stamina that is necessary to rise

early every morning, day after day, and to enter

the operating room looking forward to the day’s

challenges of 8 or 10 operations.

Although I know all of my coauthors will mention

this, I would be remiss not to mention it because it

is the single most important attribute of all: work

ethic. No one gets into cardiothoracic surgery

without an outstanding work ethic, but I notice

that many seem to lose little bits of it after a few

decades of surgery. The mental grind of operating

day after day is taxing, but it takes a finely honed

work ethic to want to try to do it perfectly each

time and not to settle for a good job when we

know that we can and should do it perfectly each

time.

GAIL DARLING, MD, FRCSC, FACS

My assigned task was to offer my reflections on

how to have a successful career in thoracic

surgery as if I was speaking with a junior colleague.

As a resident, clinical technical excellence is

usually the primary measure by which we are

judged. It is assumed that, once having passed

your examinations, clinical skills will remain at

a high level, but they must be continuously prac-

ticed, refreshed, and advanced for you to remain

at the top of your game. Clinical excellence is the

foundation of any successful surgical career.

Beyond that, the definition of success varies with

the individual. Indeed, the definition of success

may evolve over time. In my opinion, regardless

Building a Successful Career

397

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of the metric by which it is measured, to be

successful requires 4 key elements: know yourself,

do what you love, focus, and reevaluate.

Know Yourself

This is perhaps the hardest step of all: to reflect on

what motivates you, what gives you satisfaction, to

identify your strengths and weaknesses, and

decide where you want to go in your career.

When I was initially writing my list, I did not list

this as the first step but, as I thought about my

career, I realized that once I had thought about

these things and really identified who I am, what

drives me, and where I wanted to go, my career

really started to move forward. It is important to

identify your own definition of a successful career.

Success for one person may not be success for

another. Perhaps even more important is to recog-

nize that what you once considered success may

change over time.

Once you have completed this step, the next

step is to accept who you are, to be comfortable

in your own skin. Accept that what you want for

yourself may be different from what others be-

lieved, or even what may have once been your

own goals for yourself. Accept your weaknesses

and work to overcome them if possible. Focus

your career in areas of strength and interest.

Do What You Love

We work many hours in our careers. If you do not

love what you are doing, you cannot be success-

ful. You have to identify what motivates you,

what makes you jump out of bed in the morning

eager to start your day. Of course, we all have to

do the other things, but try to carve out a niche

for yourself in an area that you find interesting

and motivating. It is important to work with people

you respect and trust in an environment or culture

of like-minded individuals.

Focus

To have a successful career, you must focus.

Focus your clinical practice, focus your adminis-

trative activities or service activities, focus your

teaching, focus your research, and then write or

present seminars, lectures, and research papers

in your area of interest. You must become the

go-to person. There are many questions to be

answered, and it helps if you chose a less-

studied area. Think of good questions and set

about answering them. Structure your tasks in

readily achievable components so that each part

is successfully achieved. You can build on each

step until you complete the entire project

successfully. Present or write about each step;

do not wait for the grand finale.

Avoid distractions. Develop a list of criteria by

which you assess each task asked of you. Does

it fit in your area of focus? Is it something you

love to do or always wanted to do? Does it move

your career forward? If the request does not

meet your criteria, you may try to decline the

request or minimize the time spent on it, but

consider all requests carefully. Look ahead: is

this request or task a building block to something

more substantial?

Reevaluate

As your career progresses, make time to reevaluate.

Are you going in the desired direction? Are you on

target? If not, why not? Where did you go off track?

What will it take to get back on track? Are your goals

still the same? Do you need a change? A new chal-

lenge? What is required to follow a new course?

Know when it is time to move on.

Academic careers are usually measured in pa-

pers published, grants awarded, invited lectures,

and academic standing. Equally important are the

students we teach and motivate toward careers in

surgery, residents and fellows we have taught and

mentored who will provide care to patients and

who will go out and teach new generations of

surgeons who will in turn provide care. However,

the foundation of success is the excellent clinical

care to those who entrust their lives to us.

JEAN DESLAURIERS, MD

Thoracic surgery is a challenging and rewarding

profession in which academic surgeons have the

unique potential to make significant contributions

through their integration of clinical duties, ac-

ademic work, and research efforts. To do so,

several considerations must be kept in mind. My

personal thoughts about such considerations will

hopefully help junior colleagues be better pre-

pared and thereby contribute to their short-term

and long-term successes.

Early Years

I had the good fortune to grow up in a favorable

family environment. Both of my parents under-

stood the importance of early education and sent

me to boarding school for 12 years (ages 6–18

years). In their opinion, this was the best place

not only to learn how to read and write but, most

importantly, to develop a rational approach to

analyzing and solving problems. In those years

(1952–1964), boarding schools were also a good

place to learn to be disciplined, a factor that

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398

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I consider critical to being a successful academic

surgeon able to sustain his or her intellectual drive.

Once I completed medical school at Laval Univer-

sity (1968) and knew that I wanted to pursue an

academic career in surgery, my parents were

also instrumental in the selection of the University

of Toronto Surgical Gallie Program for my post-

graduate education. At that time, the University

of Toronto had the best Canadian residency

program in cardiothoracic surgery. In retrospect,

this decision proved to be most rewarding and

one of the defining moments in my career.

Residency Years

During my residency years at the University of Tor-

onto, I was fortunate to have outstanding personal

mentors (Drs F.G. Pearson, R.J. Ginsberg, R.J.

Henderson, and N. Delarue) who were great

leaders in thoracic surgery and had strong clinical,

academic, and educational records. These

mentors gave me the opportunity to build on my

strengths and they continued their support well

after I had completed my residency program.

They helped mature my judgment through

balanced clinical experiences and assumption of

responsibilities, as well as develop qualities of

commitment, motivation, and willingness to work

with high ethical standards. I not only learned

how to do surgery and look after patients but also

to understand thoracic diseases and their investi-

gation. I learned to write papers and how to be

part of clinical research teams. I met with interna-

tional leaders in thoracic surgery who regularly

visited Toronto and later gave me an opportunity

to present on the international circuit of thoracic

surgery. When I was Chief Resident, I was encour-

aged to foster an esprit de corps with more junior

residents for whom I had became a mentor and

these residents became, and still are, among my

best friends. To this day, I recognize the value of

my training experience, which helped me become

a good surgeon, a better human being, and

a person who learned that I was capable of much

more than I originally believed.

Early Years in Practice

Because of my background at the University of

Toronto, the transition from Chief Resident to junior

faculty member was smooth. Right from the begin-

ning (1975), I was integrated into a medical group

that understood the value of a multidisciplinary

approach to the investigation and treatment of

thoracic diseases and the importance of being

academically productive. I was able to improve

my clinical competence because my first surgical

partner (Dr Maurice Beaulieu) was exceptionally

good. He could and did get me out of many prob-

lems and was instrumental in guiding me through

the early stages of establishing my academic foun-

dation. This type of mentorship was not the same

as what had occurred during residency, being

broader in scope and encompassing clinical,

academic, educational, professional, and personal

guidance. Most importantly, I had an opportunity

for progression, which is a critical feature of an

academic and research career. Starting in clinical

research was done through the writing of retro-

spective analysis on series of patients, but all this

changed when I became one of the principal inves-

tigators of the Lung Cancer Study Group at the

suggestion of one of my mentors, Dr Ginsberg,

from the University of Toronto.

Because there is life outside the operating room,

it is almost impossible to be successful without

some degree of harmony at home and, indeed,

success and performance in the hospital is depen-

dent on happiness and security at home. Therefore,

critical to becoming an academic surgeon is paying

particular attention to family. In my case, I was lucky

to have a wonderful wife who, despite periods of

anxiety, anger, or even sadness, always supported

my work as a clinical surgeon and academician.

She was able to appreciate the difficulties in estab-

lishing an academic niche in the current market-

place and to adjust to such difficulties.

Late Years in Practice

In recent years, I have had the opportunity to add

to my surgical and personal education by being

involved in the People’s Republic of China, where

I spent 1 year as a Thoracic International Consul-

tant in 2008 to 2009. That year was invaluable

both personally and professionally, but it changed

my portfolio of value concepts and reinforced the

importance of the prior education I received during

my residency and early years in practice.

Conclusions

The keys for success as an academic thoracic

surgeon are probably more individual than has

been discussed in this essay but, overall, they

include a good surgical education, opportunities

for progression, continued need for mentorship

and support, respect of family values, and intellec-

tual honesty.

ANDRE DURANCEAU, MD

The 4 most important pieces of advice that I have

received from experienced and respected

mentors are as follows: be a good physiologist

as much as a good surgeon, focus on 1 area of

Building a Successful Career

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expertise, and learn to define the problems and

report objectively.

A surgeon starting a new academic career

needs such advice. Candidates are selected early,

based on their personality, character, education,

and accomplishments during their training.

However, the true motivation of any individual is

difficult to assess. The level of excellence for

recruitment must be set at the highest tier: ask

for more and recruit better than yourself. The result

in time will be a high-quality group instead of

a successful individual. New positions in our divi-

sion are now available to candidates with a PhD

degree in an effort to favor expertise for investiga-

tion and research. Expectations and planned

progression in academic activities must be ex-

plained to these surgeons.

Security and support for the surgeon starting in

thoracic surgery is essential, which requires an

easy integration into a well-organized group prac-

tice. Solo practice is unacceptable, especially in

a university environment. Group practice should

offer fair remuneration but also protected facilities

and time for research and encouragement for

academic participation. Our group practice model

is an adaptation of the Duke Private Diagnostic

Clinic where the base principle is the need to

invest in your own development to succeed. This

model includes transparent governance, an equal

base salary, and recognition of both clinical and

academic productivity. Expenses for meetings

are reimbursed for up to 20 days per year. Partic-

ipation in professional societies is encouraged and

their membership fees are covered. All incomes

generated by professional knowledge are pooled

and 5% of the clinical income is put into a research

and development fund, fiscally recognized as

a public foundation.

The additional expertise required by the

extended training needs to be recognized by the

university. A university position with a tenure tract

offers the best opportunity for an academic evolu-

tion. It represents security but also applies more

pressure for research and academic productivity.

With the support of our group practice and its

research and development fund, we have suc-

ceeded in creating 3 named university professor-

ships, recognizing the academic distinction of

those recruited in our Thoracic Surgery Division:

1 in lung transplantation, 1 for thoracic surgery

oncology, and 1 for esophageal diseases. These

positions are financed by funds held in endow-

ment. In time, they should guarantee support to

the thoracic surgery division for excellence in

care, education, and research.

Possibly the most difficult challenge that

remains, especially in a socialized environment,

is the unconditional support of the hospital to

meet our goals. Although these goals should be

the same for the administrator working on

a fixed-budget basis, physicians and patients are

often considered as liabilities. When asking for

new technologies and asking for more space and

personnel, the final say too often belongs to

a manager reporting to a politician.

With the best training in hand, a successful

thoracic surgery career depends on an easy inte-

gration into a successful group practice. Recogni-

tion of the outstanding expertise by the university

is essential with a teaching position that includes

a tenure tract. The hospital must commit to

providing the proper working infrastructure.

MARK K. FERGUSON, MD

My approach to this question centers more on how

to build a satisfying career than how to build

a successful career. Success in a career is easily

measured: are you respected by your colleagues,

coworkers, and patients; is the work you do impor-

tant; do you have good outcomes; have you contrib-

uted to the art and science of your specialty? Many

of the other contributors to this article outline reliable

pathways to success. Notably, just because

success is easily measured does not mean that it

is easily achieved. Following those pathways is often

difficult, and success is by no means guaranteed.

Satisfaction in a career is a more challenging

and potentially rewarding goal. Its definition can

be elusive and, being uniquely personal, is

different for each individual. Many physicians

achieve success in their careers without ever

being truly satisfied personally or professionally.

Other physicians never achieve what is generally

defined as success in their careers but derive great

satisfaction from what they do. I make no claims at

being an expert on achieving job satisfaction. I

often have been challenged by the difficulties of

making decisions that affect career success and

career satisfaction in opposite ways, and believe

the following observations are relevant. The astute

reader will note that there are conflicting sugges-

tions provided here.

Define what satisfaction means to you. Identify

what your priorities are in your personal and

work lives. Ensure that you devote as much

thought and energy to your personal priorities as

you do to your professional ones.

Learn to say no. Not everything that you are

offered, or everything that attracts you, serves

your midterm and long-term goals. Prioritize your

opportunities, identify what you can reasonably

expect to accomplish in the allotted time, and

decline what does not work for you.

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Use your time efficiently; in particular, do not let

others waste your time. Feel free to leave meetings

that are not being run effectively, that are straying

from their agendas, or that conflict with other

personal and professional commitments.

Find a niche that you love and that, within your

own sphere, you can own. This sphere will expand

substantially as your interest and expertise grow.

There are so many opportunities within our

subspecialty that it should not be a challenge to

find 1 or 2 areas to which you can fully devote

your energy and enthusiasm.

Be flexible in your thoughts and behavior. Being

open to new ideas or new ways of doing routine

tasks creates opportunities for improvement.

Change itself is not always good: there needs to

be a rationale for it, but being open to change is

always good.

Be a lifelong learner. There is nothing more

rewarding than learning new concepts, clinical

approaches, or operative techniques. Having

methods for staying on the top of your game is vital

to enjoying a career that may span 30 or 40 years.

Share your knowledge with others. Although this

is easy in an academic setting when you are sur-

rounded by residents and medical students,

opportunities still abound in a private practice

setting. Nurses and other physician extenders

will benefit from your teaching, as will your

patients, and the community at large is always

hungry for knowledge about our subspecialty.

Humbly appreciate the talents you were blessed

with and the accomplishments you have achieved.

Be thankful that you have the opportunity to work

in a respected profession that serves others.

RICHARD J. FINLEY, MD, FRCSC, FACS

General thoracic surgery has provided a chal-

lenging and rewarding professional career. After

30 plus years of practice, I still look forward to going

to work and helping patients with complex thoracic

surgical problems. I believe the key elements in

developing a successful thoracic surgery career

include education and mentorship, teambuilding,

teaching, and personal development.

Education and Mentorship

Under the direction of Dr Angus McLaughlin and

Dr John Duff, I received an excellent surgical

education at the University of Western Ontario.

The former was an outstanding educator whose

tireless effort to prepare me for the arduous

profession of surgery set the standard for my

further development in thoracic surgery. Dr John

Duff was an outstanding surgeon, educator, and

researcher. He strived to create new knowledge

in the management of uncontrolled sepsis, which

stimulated me to take further training in basic

surgical research at the Harvard Medical School.

This training allowed me to answer important

surgical questions in the area of esophageal and

thoracic surgery.

Following my general surgical and basic science

training, I was fortunate to train under Dr Griffith

Pearson and Dr Joel Cooper at the Toronto

General Hospital (TGH), at the peak of the divi-

sion’s academic and clinical accomplishments.

Dr Pearson stimulated me to follow my dream of

an academic career in general thoracic surgery,

which has come to fruition thanks not only to the

mentorship of Drs Pearson, Cooper, Ginsberg,

Todd, Delarue, and Henderson but also to

colleagues who understand the role of academic

surgery in the care of the patient needing general

thoracic surgery.

Based on this experience, my advice to resi-

dents and young academic general thoracic

surgeons is to get the best education you can

and establish yourself as an excellent surgeon

whose primary interest is the safe care of the

patient. Be professional in every encounter with

patients, colleagues, and staff. Become an expert

in 2 or 3 areas in general thoracic surgery, study

the history and development of these subspecialty

interests, and join societies in which these inter-

ests can be nurtured and a network of colleagues

can be fostered. Develop research questions in

these areas that can be answered with good

science, followed by presentation and publication

at peer-reviewed meetings. In addition, thoracic

surgery will continue to change. General thoracic

surgeons must practice lifelong learning through

reading journals and attendance at meetings. It is

important to keep up to date in new technology

and processes in order to play a leadership role

in the management of the patient with thoracic

diseases.

Team Building

A successful career depends on excellent multi-

disciplinary patient care, education, and research

teams. First and foremost are your fellow general

thoracic surgeons in your division. These col-

leagues need to be excellent clinical surgeons

with dedication to the development of the

academic thoracic surgery team. Although their

interests may vary, their primary focus is on treat-

ing the patient who needs thoracic surgery in

a caring and evidence-based manner. Secondly,

the clinical support staff is an essential part of

dealing with the complex and arduous workload

associated with general thoracic surgery. The staff

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needs to be well trained and dedicated to patient

safety and quality improvement. Stimulating part-

nerships with respirologists, gastroenterologists,

otolaryngologists, anesthesiologists, oncologists,

and pathologists are essential for excellent patient

care and creative research.

Teaching

The most satisfying aspect of my job is ensuring

that our students, residents, and fellows receive

the best clinical and academic training available.

I recommend that the resident should have at least

a Masters degree in epidemiology, education, or

a basic science research in order to sustain their

academic career. After these residents have grad-

uated, it is important to maintain communication

with them to support their development.

Personal Development

In order to lead others, you must manage yourself.

Many brilliant thoracic surgeons have destroyed

their careers with unprofessional activity. You

need to make time for yourself and your family.

You must keep yourself fit, mentally and physi-

cally. Develop hobbies and a life outside surgery

in order to broaden yourself. Despite the chal-

lenges of modern thoracic surgery I envy those

who will practice this rewarding specialty in the

future.

MICHAEL R. JOHNSTON, MD, FRCSC

Success means different things to different

people. To me, it is being able to do what I want

to do when I want to do it. This view may be

a simplistic, but it encapsulates what I think are

the most important prerequisites for becoming

a successful thoracic surgeon:

1. Broad training that leads to broad perspectives

and more opportunities

2. Research experience keeps the door open for

academic pursuits in the future

3. Always striving to be an effective educator

4. Awareness that mentoring involves much more

than educating

5. Being an effective, compassionate communi-

cator builds trust and confidence in patients

and their families.

Success is a career-long pursuit. Some of us

may be fortunate enough to practice in the same

location and rise through the ranks for our entire

career. But for most of us, including myself, during

those 30 or 40 years of our professional life,

options are encountered by choice or by necessity

that will significantly alter our career pathway.

Whether it is promotion, or salary, or protected

time, or research support, at some point you

believe you need to draw a line in the sand.

“Meet my demands or I leave.” Just remember, if

your demands are not met and you stay, your

credibility is worth about as much as a subprime

mortgage, so know your alternatives before you

issue your ultimatum.

When career options arise, the choice may be

obvious and is usually dictated by that old adage

“Never make a lateral move.” If only it were that

easy! But factors seemingly extraneous to our

career often get in the way of the obvious. Factors

such as family, friends, geography, politics, and

even health may make a seemingly easy decision

difficult. Transitions are hard and do not always

end up being career enhancing. My advise is to

carefully weigh the choices, make the decision,

and never look back.

Once in a new position, possibly a new hospital

or university, or, in my situation, a new country,

one has to look at the opportunities available,

which is where broad training and experiences

really pay off. I moved from the University of Colo-

rado in the early 1990s to the University of Toronto

just as the likes of Cooper, Ginsberg, and Patterson

were heading south. Bad timing or good opportu-

nity? It could have been either, but I believe (admit-

tedly in hindsight) it turned out to be the latter.

To be recognized as a leader and an expert, one

eventually has to narrow the scope of practice,

probably from both clinical and research perspec-

tives. Thoracic surgery is just too large a field to be

proficient in all areas. I must confess that I mostly

decided what I no longer wanted to practice rather

than actively deciding what to pursue. I was always

drawn to thoracic oncology, but along the way I

dropped cardiac, thoracic vascular, transplant,

and benign esophageal practices. A combination

of interest and opportunity were undoubtedly the

determining factors.

Once you see yourself heading in a certain career

direction, it is time to actively focus. Research and

clinical practice should reflect that focus, as should

educational pursuits. Join the appropriate highly

focused organizations (over and above the national

thoracic societies) and take courses that will

enhance your knowledge in that focused area, be

it surgical education, minimally invasive surgery

(MIS), or biomarker validation. Spending time with

experts in that particular field is essential. After 3

years at the National Cancer Institute, I had

a reasonable idea of cancer clinical trial design,

but only after an in-depth experience with Drs

Mac Holmes, Griffith Pearson, and other notables

in the Lung Cancer Study Group could I comfort-

ably claim to be proficient in the field.

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In my career I have worked with some excep-

tional surgeons and basic scientists. I have prac-

ticed both cardiac and general thoracic surgery

in private, university, and Veterans’ Affairs settings

and in 2 countries with very different health care

systems. I have held peer-reviewed funding for

both basic and clinical research. However, for

me, the most gratifying and personally rewarding

element of my career has been the mentorship of

students, residents, and fellows. Being a mentor

is more than merely educating these bright young

people. It is role modeling and leading by example.

It is advising and counseling for their best interest.

It is also critiquing and criticizing in a manner that

constructs rather than destructs. The rewards are

the pure satisfaction of having influenced and

shaped a career, and a lasting bond of gratitude

from a group of eager, but highly vulnerable,

trainees who now are your peers.

MARK J. KRASNA, MD

After a nearly 20-year academic career, what

makes a thoracic surgeon get up one morning

and say “I’m going to do something different”?

One is satisfied that you have helped hundreds

of patients each year. You even believe that you

have developed those unusual skills of knowing

when not to operate, as well as the audacity to

know that there are certain procedures that you

can do that few others would ever try to do. You

have enjoyed training students, residents, fellows,

and postdoctoral students who have themselves

gone on and become successful thoracic

surgeons around the world. So why stop? What

would be the career move that would give the

most satisfaction? The next step can be more of

the same: a lateral move to another institution

where you can make a new or larger program or

develop an existing program successfully. One

could always go to the obvious next step in the

academic food chain and become a chairman of

a department of surgery. Having worked within

the department at many administrative levels, the

department head option was not for me.

What I wanted was to make the greatest impact

on patient care and the future of thoracic surgery,

integrated with the other oncology disciplines. I

had successfully developed a thoracic surgery

division and initiated a thoracic oncology program.

In addition to implementing biweekly prospective

cancer conferences, we developed true multidisci-

plinary thoracic oncology clinics. We began repli-

cating this model in other disease sites when I

served as associate director for multidisciplinary

care within the Cancer Center. Then I realized

that the next step was obvious: become a cancer

center director! Although I was able to perform 400

thoracic procedures a year, and my division as

a whole was able to perform more than 1200

procedures a year, my thoracic oncology program

treated almost 3000 patients a year. As cancer

center director, I would be able to have a unique

impact on the care of thousands of patients.

Although I looked at many opportunities at single

institutions in academia and the community

setting, I ultimately chose to join a large health

care system. The system included 79 hospitals

from coast to coast, and would enable me to reach

more than 60,000 new patients with cancer a year,

with a total of more than 250,000 patients with

cancer within our system. This impact was what I

was looking for.

What are the skills that enable a thoracic

surgeon to become a cancer center director?

We thoracic surgeons are uniquely situated to

understand the value of multidisciplinary cancer

care. We understand team work and team

building. We can learn to leave our big egos at

the door when we enter the examination room or

conference and put the patient’s needs first while

implementing multidisciplinary cancer care.

The additional skills that thoracic surgeons

possess to accomplish this include leadership,

compassion, reliability, and our let’s-get-things-

done approach. This impatience helps us achieve

more hard-to-reach goals faster than others. We

are used to thinking outside the box and rapid

problem solving, with unique abilities to adapt to

changing realities. We respond well to change; we

recognize a problem, analyze it, make a decision,

and then launch into action. Autonomy is one of

the traits that thoracic surgeons crave, and, in the

milieu of health care, this is one that is often chal-

lenged. The ability to maintain autonomy and affect

health care on a broad scale is, again, one of the

attractions of being a cancer center director, where

a reporting structure directly to the CEO or Board of

Directors is possible. Although there is no formal

training in most residency and fellowship programs,

thoracic surgeons become leaders naturally in the

course of their training. Bringing a whole team

together to follow a strategic vision is challenging,

but thoracic surgeons are used to being the captain

of the ship and leading by example. This ability is

learned when performing major cardiac and

thoracic complex procedures that require commu-

nication with a large team made up of different

specialties. Leading that team by example, earning

and then commanding respect and rewarding team

members, is one of the first lessons that the resident

develops in training.

Once the decision is made to become a cancer

center director, thoracic surgeons needs to marshal

Building a Successful Career

403

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their skills to best succeed, which includes multi-

tasking, continued learning, and, in particular, ex-

panding the scope of our knowledge base:

understand the other cancer specialties by reading

their literature and participating in multidisciplinary

conferences and educational programs. This

process positions thoracic surgeon leaders to be

serious and knowledgeable contenders among

their colleagues, and be respected for decisions

that affect all aspects of cancer care. In addition

to participating in annual thoracic surgery confer-

ences, I have also maintained a presence, at least

once a year, at national oncology conferences.

In addition, surgeons must learn and understand

the business of medicine and of cancer care in

particular. This learning does not necessarily

mean getting a Master of Business Administration

(MBA), but at least a basic knowledge of budgets,

strategic plans, and vision goals is required. Suc-

ceeding on the business side of health care today

is a necessity in order to achieve a greater impact

on improving patient care. Seeing the forest and

understanding each of the trees and their

surrounding environment is a gift that thoracic

surgeons generally have. We realize that patient-

derived revenue is generally dependent on refer-

rals, which is dependent on relationships with other

physicians. As thoracic surgeons in a competitive

environment, we know better than most the impor-

tance of communication with referring physicians

and keeping primary care doctors in the loop and

not feeling left out. Other sources of revenue that

the thoracic surgeon director can bring to the insti-

tution include fundraising and grant procurement.

Leaving academia does not mean leaving

academics. A thoracic surgeon cancer center

director in a community setting should strive to

publish programmatic data, and encourage other

staff from the various disciplines to do the same;

this not only is good marketing and public relations,

it truly allows the team to assess its own results

critically and contribute to the body of scientific

knowledge. In addition to involvement in clinical

trials through cooperative groups or industry spon-

sored research, National Institutes of Health (NIH)

grants are available for clinical as well as basic

science research in the cancer arena, including in

nonacademic centers. Our current NIH/National

Cancer Institute (NCI) grant and subcontract

awards exceed many academic departments in

dollar amount and scope of projects.

In conclusion, I paraphrase what I learned from

Dr Denton Cooley on grand rounds one day in

the Children’s Hospital in Boston, “Codify (your

ideas), modify (to fit the specific environment),

simplify (the process to make it easy and repli-

cable), and apply (the new paradigm to your

setting).” If one can transcend the personal satis-

faction of doing a case, rise above the challenges

of leading an operating room team, a thoracic

surgeon can make an even greater difference as

a program leader.

For more information on leadership, 2 classic

books I suggest are Leading change by J.P. Kotter

(Harvard Business School Press; 1996) and On

Leadership: Essential Principles for Success by

D.J. Palmisano (Skyhorse Publishing; 2008).

TONI LERUT, MD

In November 1973, when I was in the final phase of

my residency in surgery, my Chief Professor Jac-

ques Gruwez invited Mr Ronald Belsey to be

a keynote speaker at an international symposium

at our institution. Six months later, a letter from

Mr Belsey arrived on my desk announcing

a vacancy for a senior resident in his department

at Frenchay Hospital, Bristol, United Kingdom. I

was offered the position and went off to Bristol

for what became a dazzling experience and the

turning point in my career.

Being a brilliant surgeon, original thinker, and

superb teacher, Belsey, in those days named

The Pope of Esophageal Surgery, shared his skills

and knowledge through personal example with the

benefit of a masterly command of the language.

Not surprisingly, this unique experience triggered

my interest in thoracic surgery, as it most likely

did for many of the approximately 45 other interna-

tional trainees who became influential leaders in

thoracic surgery.

Following residency, it was not clear to me

whether I would pursue a career in private practice

or in an academic environment. Being inspired by

Mr Belsey and realizing that only a few centers

focused on thoracic surgery, I decided to pursue

an academic career.

Some years later, again through Mr Belsey’s

influence, I was offered a scholarship to the

University of Chicago where I met Drs David

Skinner and Tom DeMeester. They both intro-

duced me to the wonders of esophagology and

widened my thoracic horizons by bringing me in

contact with Drs F.G. Pearson and Joel Cooper.

My exposure to their pioneering work in lung trans-

plantation became the basis for starting our own

lung transplantation program. Other inspiring

leaders who have influenced my career include

Dr Alberto Peracchia from Italy and Dr Hiroshi

Akiyama from Japan. From this review of my

career, it is clear that building a successful career

is a gradual and multifactorial process.

To begin, I clearly had a great deal of luck. To be

trained and mentored by a giant in thoracic

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surgery was the result of a coincidence, and that

training allowed me to stand on the shoulders of

a visionary leader and thus to be able to look a little

bit further than my fellow colleague residents at

that time. Perhaps luck favors a prepared mind.

The willingness to leave one’s own safe environ-

ment and to take on the challenge of a foreign

environment and medical system was critical to

my success.

Second, building a successful career requires

the capacity of self-assessment. You need to

assess yourself continuously in order to know

what you really want to obtain in life (eg, to choose

between a career in private practice or an

academic career).

Third, because today’s medicine is evolving at

an incredible pace, it is of paramount importance

to prepare for a lifelong learning process and a crit-

ical analysis of one’s own results. These goals can

be accomplished locally but also by attending

international meetings and by fostering interna-

tional contacts through international scientific

society activities.

Fourth, building a successful career requires

teamwork. This teamwork needs to be first of all

within your own group. It is of paramount impor-

tance to be surrounded by outstanding col-

leagues. Taking advantage of having built an

international network allowed me to offer my

coworkers and future partners the possibility to

obtain additional training in centers of excellence.

These colleagues were sent to these centers to

focus on 1 or more particular areas of interest

that would later allow them to return to our group

with this expertise. Offering such opportunities to

excel creates job satisfaction and team spirit that

is essential for guaranteeing the highest quality

of care. The result has been that I have been priv-

ileged to work with an outstanding group of

thoracic surgeons during my career. The other

essential component of teamwork is multidisci-

plinary. Surgeons need the interdisciplinary skills

of a wide spectrum of disciplines with whom we

have to work on a daily basis. To work in such

an environment requires sufficient emotional intel-

ligence and social skills.

Building a successful career in thoracic surgery

requires a permanent belief in your dreams. To

quote Eleanor Roosevelt, “the future belongs to

those who believe in the beauty of their dreams.”

JAMES D. LUKETICH, MD

The development of a junior faculty member in an

academic setting is a challenging endeavor. After

a long and arduous residency, a young faculty

member will face many challenges at any institution.

There are various pathways that can be pursued to

climb the academic ladder. It is important to have

a detailed discussion with the Cardiothoracic Chief

or Chairman as to your goals and his or her expec-

tations. Make sure that you do not choose a path

determined only by what a Chairman or Division

Chief is seeking, but also find a position with

a pathway that excites you and is best suited not

only to your background and skill set but also to

your personal strengths and passion. Preliminary

discussions of your goals and the Chairman’s

expectations are crucial to your ultimate success

and happiness in your new environment. The ideal

institution is one that has adequate resources and

mentoring that will allow you to succeed and one

that places an emphasis on research at a level that

is compatible with your personal goals.

The potential tracks for junior faculty surgeons in

an academic setting include both a tenure track

and a non-tenure track. It is critical to identify

a focus for your work whether clinical care, teach-

ing, research, or program development. Advance-

ment in the tenure track is most frequently

accomplished by the route of the surgeon-scien-

tist, whereby one develops a focused research

effort, characterized by originality of work, publica-

tions, grant funding, sustained productivity, and

achievement of national/international reputation.

This has traditionally been laboratory-based basic

science research. Generally, a junior faculty mem-

ber is expected to obtain extramural funding within

1–3 years of his or her appointment in the form of

a start-up grant. Following this early success,

achieving tenure in most institutions requires

peer-reviewed publications, national presentations

and additional grant funding at a more senior level

such as Research Project Grant (R01) funding.

For most competitive academic institutions, tenure

promotion is a slam dunk if a clinical faculty

member obtains R01 funding, assuming other

requirements are met (for example, teaching

medical students, institutional academic service,

and a track record of publications in the area of

the funded research).

Having a focused effort that encompasses basic

science work and clinical and teaching efforts has

certainly been a part of my success. I was interested

in esophageal surgery, so I devoted significant time

and energy to developing a clinical practice that

included benign and malignant esophageal surgery.

I developed early collaborative relationships with

local and regional medical oncologists, gastroen-

terologists and other surgeons interested in esoph-

ageal disorders. The availability of corporate and

industry funding to develop research and clinical

studies related to minimally invasive esophageal

surgery also facilitated my success. All of these

Building a Successful Career

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led to peer-reviewed publications. Referring doctors

began to associate our research with good clinical

outcomes for their patients, and my clinical volume

continued to grow. The relationships I developed

with basic scientists helped me strengthen my

own hypothesis-driven basic science research

and improved my grant writing skills. While having

a busy clinical practice that is directly related to

your research is not essential, it gives you obvious

advantages. Your clinical material can also support

a tissue bank to facilitate your basic science

projects and that of your colleagues. If you focus

on research, focus your efforts on a specialized

area of concentration. A common error is the

tendency to be too diffuse.

Another route that can be pursued is one of

a clinical investigator, although advancement for

tenure promotion may be more difficult compared

with the classical basic science model. This route

may also provide satisfying advancement along

a non-tenure track. These efforts can start with

a more modest time commitment to research

and can result in leadership positions in intergroup

trials.

Outstanding contributions in teaching or innova-

tion can also demonstrate that one’s work and

career path are worthy of tenure. If you have spent

considerable time successfully developing or

improving a technique, as documented by publi-

cations, invited lectures and professorships, and

other indicators of prominence in thoracic surgery,

this may be considered a strong factor for tenure.

A clear focus on education, particularly developing

and providing medical student education, is

necessary for advancement as a physician-

educator. To be a surgical educator, you have to

gain formal knowledge in education. Teaching

awards provide documentation of excellence.

At our institution, advancement in the non-

tenure track is similar to tenure track advance-

ment, with a few notable exceptions. This track

focuses on individual accomplishment, program-

matic contributions and progressively increased

responsibility over time. Being considered a role

model by medical students, postgraduate trainees

and junior faculty and a record of high quality

patient care are also important. Less emphasis is

placed on leadership and the ability to obtain

external funding.

Although it is evident that you have to work hard,

it is important to maintain some balance. Finally,

be persistent and organized in your efforts.

DOUGLAS J. MATHISEN, MD

Building a successful academic career starts in

medical school. The fund of knowledge acquired

is the foundation for the rest of your medical

career. An academic interest usually develops

while in medical school and sets in motion the

necessary elements to a successful academic

career. Performing well in medical school opens

the door to the best available residency training.

The place in which you train creates an imprint

that follows the rest of your career, and this is

especially true for your cardiothoracic residency.

Where you train influences your abilities as

a surgeon. You will have a lifelong association

with your fellow trainees, those who precede you

and those who follow. You become members of

the same club! Your cardiothoracic residency

has a great impact on getting your first job. Next

to choosing a mate and whether or not to have

children, fellowship training is one of the most

important decisions of your life.

Residency training usually introduces you to the

most important mentors in your life. They will be

the ones who nurture you, educate you, and point

you in the right direction. They are likely to bring

out the desire in you to become an academic

surgeon and educator.

Your first papers and presentations in your field

are likely to come from your time as a resident.

The cardiothoracic residency should be devoted

to mastering the fund of knowledge and honing

your technical skills. No matter what your ultimate

career goal, being an outstanding surgeon clinician

is the foundation on which to base everything else.

During general surgery residency, many choose

to pursue time in a research laboratory. This

choice may relate to what you pursue after

completion of residency, but not necessarily.

However, it should lay the foundation for scientific

pursuit. With luck, it will still be applicable years

later. In addition to being productive in the labora-

tory, this time should also be devoted to expand-

ing your knowledge base; in surgery in general,

and cardiothoracic surgery in particular. There is

never enough time to read but, if you delay it, to

your fellowship you will always be behind. Read,

read, read.

As a young faculty member, it is important to

choose a strong institution and a great person to

work with. Choosing the right people to work

with is the most important factor in early job selec-

tion. If you have chosen wisely, they will support

you, provide you with opportunity, come to your

aid in a crisis, and be there to fill in when you are

away. Great colleagues ensure that you will look

forward to coming to work every day.

Early on in your career you must develop the

discipline to become productive. It is difficult to

acquire later in your career; clinical demands will

monopolize your time. You must extend yourself

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to write, give lectures, and participate in meetings.

I always adhered to the philosophy of never saying

no. If I said yes, I always did what was required and

preferably on time. A good mentor should provide

opportunity. What you do with it is up to you. I

believe you should not narrow your interests too

soon, but start to develop an area of special

interest. It is then important to develop a body of

work around this area of interest. This work can

be clinical, basic research, outcomes research,

or any number of things. It should be something

you enjoy: it is not work then, it is fun! There are

many pathways to academic prominence.

If you choose to pursue a basic science labora-

tory effort, it is best to start early in your career

before clinical demands make it impossible. It is

important to have a supportive mentor to help

navigate all of the vicissitudes of laboratory work

and funding. Joining an established laboratory

accelerates your career and is the best approach.

A laboratory effort brings personal satisfaction and

acclaim to your group. One must recognize the

challenges of trying to balance all of the demands

of clinical, research, education, and family life. One

should emphasize the importance of developing

a balance between your professional life and

family life, especially in the ascendancy of your

career, when family and professional demands

are often in greatest conflict. Your family must

not be shortchanged! Every person is different in

how they achieve balance; there is not 1 prescrip-

tion that works for everyone. It is important to find

what works for you.

Throughout your academic career, making the

residents you train a priority will always be effort

well spent. You will develop a loyal following who

will always add to your success. They will work

for you, produce academically for you, and help

you recruit other great residents in the future.

Focusing on residents and their training is amongst

the best investments in your academic life.

If you are fortunate enough to then be involved in

the direction of a surgical group, putting together

that group requires a great deal of thought. I

have always thought of it as building a puzzle.

Each piece is important and must fit.

Each member should contribute in a specific

way. I have always believed each member has

something to call their own. This approach allows

the group to have broad interests. Carving out

a niche for each develops expertise and improves

work satisfaction. The group must be compatible,

respectful of one another, supportive of one

another, and put the interests of the group ahead

of the interest of the individual. This collective

effort will work to strengthen the group and

generate recognition for your group.

This approach creates a collegial atmosphere

and a desirable place to both train and work for

others. Groups that are not put together with fore-

thought and with an eye toward compatibility often

become dysfunctional. As the leader of the group,

one should strive to treat each member fairly,

trying to promote their interests. If the members

of your group are successful, you will be success-

ful. It is important to devote time to promote your

colleagues in their career. They will respond in

kind by contributing to the group effort and remain

committed to your vision.

I have always believed it best to stagger recruit-

ments so that there is a range of ages within the

group, allowing advancement and progression of

the individual. This range also allows for orderly

transition of people coming and going within the

group or, ultimately, the retirement of you as the

leader of the group. It is important to plan for

succession to maintain the integrity of the group

and have a long vision, not just ending with your

retirement.

Planning for retirement is just as important as

any other stage of your career. It is not just finan-

cial planning but how to keep your mind engaged

and physically involved. If you have done a good

job of organizing your group, you will continue to

be a valued member well into your retirement.

The wisdom and judgment that you have acquired

over the years will be seen as a valuable contribu-

tion even in your retirement years.

Careful planning at all phases of your profes-

sional life creates a rewarding career, in which

you also contributed to your profession, devel-

oped your own professional life, and contributed

to the development of your colleagues.

ROBERT MCKENNA JR, MD

Building a successful career starts during training.

Find a gimmick. Although it is difficult to predict

the future, pick an area of cardiothoracic surgery

that really interests you. Get training that makes

you marketable and unique. When I was in medical

school, I told my wife that I would not be just

another general surgeon who could perform

a cholecystectomy like 10,000 other surgeons in

Los Angeles. Take courses or additional fellow-

ships (eg, video-assisted thoracoscopic surgery

[VATS] lobectomy, MBA) that make you different

from others so that potential employers want you.

Find a job in an environment that allows you to

be successful. It is important to operate, so you

need a job that gets you busy soon. Ask from

where your cases will come. What is the marketing

plan? Find a niche in the group, such as maze

procedures. Select patients who will do well after

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your procedures. If you turn down cases that

should not be done, referring doctors will respect

that good judgment. Spend plenty of time with

your patients. A good consultation for lung cancer

includes showing the patient the computed

tomography scans and discussing diagnosis,

natural history, treatment options, and recovery.

Patients will appreciate the time that you spend.

A happy patient is your best marketer by telling

their doctors and their friends how happy they

are with you. Communicate well with referring

doctors regarding consults, postoperative results,

and follow-up.

Get involved in hospital activities. After a few

years in practice, time for committees becomes

limited, but there is plenty of time when starting

a practice. Committees and hospital activities

help you to get to know physicians at the hospital.

Other marketing can also help to build a career.

Give as many continuing medical education

(CME) talks as possible. Clinical research helps

keep you current and leads to journal articles

that can be the basis for the CME talks. Giving

a talk about your own experience and your data

helps others to recognize you as a knowledgeable

leader in the field.

Find a mentor. A job with cardiac surgeons who

want you to develop a general thoracic program is

not ideal. It always helps to have another surgeon

whose specialty is the same as yours so that you

can discuss cases and the program. It is difficult

to be isolated as the only one in the group to do

a specialty.

Ultimately, thoracic surgery is a great specialty.

As Dr David Sugarbaker says, “Find a job, and

make it the right job.” Good luck.

F.G. PEARSON, MD

Background

When I began surgical residency in Toronto in

1955, general thoracic surgery was still a subspe-

cialty within the Division of General Surgery in

North America. I was appointed to this subspe-

cialty group in 1960. My professors at Toronto

General Hospital and the University of Toronto

were Drs Robert Janes and Frederick Kergin.

Both were general surgeons who made pioneering

contributions to the subspecialty of general

thoracic surgery.

Cardiac surgery became an exciting and rapidly

growing discipline during the 1950s, and residency

programs were established in the combined

subspecialties of Cardiovascular and thoracic

surgery in almost all centers in North America

and Europe. However, Toronto established a sepa-

rate training program in Cardiovascular Surgery in

1958, headed by William Bigelow. Bigelow,

another TGH General surgeon, was a pioneer in

Cardiac and Vascular surgery, but was never

a thoracic surgeon.

In 1967, Dr Norman Delarue and I requested and

were granted the opportunity to restrict our clinical

practice to general thoracic surgery in a separate

surgical division. Approval and support for this

initiative was given by the then Professor of

Surgery at University of Toronto and TGH, Dr Fred-

erick Kergin. This approval provided the University

of Toronto and TGH with a unique early opportu-

nity to develop an academic residency training

program in general thoracic surgery. A history of

the evolution of this surgical specialty in Toronto,

and subsequently throughout Canada, is detailed

in Pearson’s Thoracic and Esophageal Surgery

textbook.1

A Successful Career in General Thoracic

Surgery

Clinical training

All candidates should seek the best possible clin-

ical training experience. The program should

include general surgery, ideally providing 1 year

at the senior resident level. Proficiency in both flex-

ible and rigid endoscopy is an invaluable asset

which is not sufficiently emphasized in some North

American programs.

The inclusion of esophageal surgery is strongly

advised. Esophageal surgery is often difficult,

and technically challenging. Good results in

benign conditions may be demanding, but are

very rewarding for patient and surgeon. Further-

more, esophageal surgery remains in no man’s

land, and is not perceived to be the province of

any particular specialty.

Mentoring

An important mentor was my elementary school

science teacher, Dr A.G. Croal. His interest, skill,

and enthusiasm made the biologic sciences

a fascination. In my final year of high school, he

persuasively advised me to become a physician

rather than a high school science teacher. His

message was, “Medicine provides many more

options, and you may still end up teaching

science, among many other opportunities.”

Surgical mentors include Professors Janes and

Kergin in Toronto. They arranged my residency in

Ronald Belsey’s Regional Thoracic Unit in the

west of England. Belsey profoundly influenced

my career, transmitting his unique experience

and his original and innovative technical skills. He

imbedded in me, and in many other international

trainees, the critical importance of a good history

(listening to the patient), unbiased observation,

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and learning from one’s mistakes. In the history of

thoracic surgery, Belsey plays a pioneering role in

championing the educational importance of long-

term follow-up. He was an inspiration, friend, and

supporter until his death in 2007, at the age of 97!

In a residency training program, the opportunity

to act as a meaningful mentor is a gift and

a rewarding opportunity.

Team building

The ability to work effectively in teams is invaluable,

and becoming increasingly the norm in relation-

ships with other specialties. Thoracic surgeons

perform more effectively and more enjoyably

working in collaborative groups and partnerships.

Diminishing the incentive for economic competi-

tion between partners is potentially a positive

feature in most successful, enduring groups.

Learning and education

Change and new information are increasing at ever

more daunting rates. The need to assimilate and

adapt is fundamental to our discipline, and

increasingly favors identifying foci of special

interest and expertise.

Retirement

To quote Ronald Belsey at the beginning of my

residency on his service, “Young man! You must

begin planning for your retirement on the day you

begin practice!” He was referring to the pleasure

and importance of outside interests and hobbies

in a busy surgeon’s life. He lived his philosophy,

and pursued his extrasurgical interests throughout

his career and long after his retirement from the

British National Health Service.

CAROLYN E. REED, MD

As I sit and interview candidates for cardiothoracic

surgery, I am awed by the intelligence, talents,

motivation, and altruism of these individuals.

However, some actually ask me how I became

a successful thoracic surgeon! It forces me to think

back over a 25-year span of time, realize how

much has changed in medicine, and focus on

what enduring traits and activities are important

to initial and, more importantly, ongoing success.

The first requisite is passion. Passion for your

work fuels the long days and nights, overcomes

the disappointments, and sustains the drudgery

(eg, bureaucracy of paperwork, politics) It may not

be immediately apparent how to focus this passion,

but inevitably, in the first 5 years of your career, the

niche that makes you tick becomes evident and you

become more focused. There are many areas in

thoracic surgery in which to excel, whether it is by

clinical patient-oriented expertise, translational or

basic science, education, administration, or health

care policy. It is unlikely today that one can be

successful in all the components, but it is important

to recognize and value the whole.

To be successful, you must recognize and seize

opportunities. Such behavior implies flexibility,

willingness to welcome change and innovation,

and the lack of fear to risk failure. The ability to

change is difficult for individuals, and as people

grow older, they tend to narrow the scope, not to

widen it. Nowhere is it more clear than in the recent

developments in thoracic surgery that such

behavior invites failure.

This brings me to the third requisite to a success-

ful career: a dedication to self-renewal. In medi-

cine, particularly in emerging technologies,

molecular medicine, changing climates of health

care delivery, and so forth, the potentialities are

endless. I recommend the book Self-Renewal by

J.W. Gardner (WW Norton; 1995) to my colleagues.

Inevitably, some candidates, particularly women,

ask how these enduring qualities applied personally

to me. I first would say that it was a different time and

place, but specifics may be helpful. I was never

going to be a cardiothoracic surgeon, but I found

the passion (general thoracic oncology) during

a surgical oncology fellowship. I seized the opportu-

nity to do a cardiothoracic residency and never

looked back. I chose a job in which I felt I could

make a difference in patient care and resident

education, and there was nobody but myself to

build and lead a multidisciplinary team in general

thoracic surgery. As a woman in a field populated

by the other gender, I was often the token

committee member at the local or regional level. It

did not bother me because I used the opportunity

to learn new skills, broaden my horizons, and

meet new people, some of whom would become

mentors. I was fortunate that my senior colleagues

fostered my national career, and it was important

to me and the women who have followed, and will

follow, that these activities were successful. I think

I put some cracks in the glass ceiling.

My success in thoracic surgery will always be

embedded in my clinical work. Caring for the

patient is the bedrock of medicine. It is bother-

some that some individuals stray away. Each

patient’s thanks, hug, or letter is a measure of

a successful career. Over the years I have kept

a record of these tributes, and it is stark evidence

that one can make a difference. I try to instill in my

residents that everyone is capable of this measure

of success. I suggest that prerequisite reading for

all residents should include How Doctors Think by

J. Groopman (Houghton Mifflin Co.; 2007).

The imparting of my skills, judgment, and values

to the future of thoracic surgery, the residents, is

Building a Successful Career

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a daunting task. However, the reward is great.

When a resident calls with excitement and pride

to relate how he or she has accomplished

a complex procedure you taught, you experience

success.

I do not know if I belong in the category of influ-

ential thoracic surgeons. However, in the eyes of

my patients and residents, I know I have made

a difference, and that is enough for me.

JACK A. ROTH, MD, FACS

I have been asked to describe from my perspec-

tive what it takes to build a successful career.

Success is in the eye of the beholder. I would first

advise that one not strive for career achievements

that will be believed to be perceived by others

as hallmarks of success. Success should be

measured by personal satisfaction and does not

require external validation. In my experience,

pursuit of success as a goal is elusive and the

real rewards are to be found in the journey. I

have been fortunate to have a career that

combined thoracic oncologic surgery with clinical

and laboratory research, resident and fellow

education, and departmental administration. This

combination does not appeal to everyone, nor is

it in any way a prerequisite or formula for

a successful career. Although this was a career

track that defined many prominent academicians

in the past, the complexities of contemporary

surgical practice, research, and education have

contributed to the abandonment of the triple threat

as a realistic goal. Career success can be

achieved by pursuing 1 of these areas in depth.

The choice of thoracic surgery as a career was

critical for me. As a medical student, I was fasci-

nated by the anatomy in the chest and also real-

ized that there was an unmet need for treatment

of thoracic cancers, with few surgeons in the

specialty. Planning your fellowship training to

meet future unmet needs in areas with a shortage

of specialists can make one very much in demand.

I have been privileged to practice thoracic surgery

in 2 great institutions: the NCI and the University of

Texas MD Anderson Cancer Center (UTMDACC). I

have also been privileged to have worked with

many outstanding surgeons as mentors and

colleagues. Although much of my career has

been devoted to clinical and laboratory research,

the uninterrupted practice of thoracic surgery has

always been important to me because it is person-

ally rewarding to treat patients, intellectually chal-

lenging to deal with complex cases, and useful to

keep in touch with the critical clinical questions

and current technical advances in diagnosis and

treatment. Clinical and laboratory research has

been an important component of my career. The

surgeon scientist contributes to progress in our

specialty, and thoracic oncology presents many

novel and important research opportunities with

the potential to make advances in patient care. If

you choose this path, a 2-year to 3-year research

fellowship in a top-tier laboratory is a requirement.

The variety and consistent challenge of combining

research and patient care contributes to career

longevity and avoidance of burnout. For those

readers interested in a thoracic surgery research

career, I present a brief perspective on some prin-

ciples that have been useful to me in choosing

areas for scientific investigation.

Maintain an Active Clinical Practice

Throughout Your Career

Technical mastery and expertise in thoracic

surgery is required. Continuous exposure to chal-

lenging clinical problems provides inspiration for

formulating important research questions. You

will also be prepared to translate new diagnostic

tests or therapies to clinical practice.

Focus Your Research on Problems Related

to Your Specialty

The clinic and operating room are laboratories.

Many of our treatment strategies have suboptimal

or unproven efficacy. In designing clinical re-

search, it is important to be pragmatic as well as

innovative. A clinical trial may be interesting but

impossible to complete because of a lack of

patients or resources. Investigate the most impor-

tant clinical problems despite their difficulty.

Answers to trivial questions result in only an incre-

mental advance at best and still require great time

and effort. An important corollary is that problems

should be chosen that can be solved with current

technology or technology that can be readily

developed. My clinical research early in my career

exemplifies this concept. The outcomes from

surgical treatment of lung and esophageal cancer

were dismal when I began my career at the NCI.

However, for the first time, new platinum-based

chemotherapy was shown to cause tumor regres-

sion in a high percentage of cases. Because most

relapses were systemic metastases, it seemed

logical to give chemotherapy preoperatively

when metastases could not be detected clinically

and tumor shrinkage could facilitate surgery. I initi-

ated the first randomized trials in preoperative

therapy in lung and esophageal cancer.2–4

Although the trials were small, the results provided

direction for future clinical trials and stimulated

research.

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Investigate Research Questions that Have

Biologic Relevance

If you have a laboratory or collaborate with labora-

tory scientists, investigate research questions that

have biologic relevance. Cancer research prog-

resses in increments, and the likelihood of making

a major therapeutic breakthrough is low. However,

carefully designed experiments and clinical trials

yield important biologic insights that may point to

a new direction. For example, for many years our

research group has been studying genetic abnor-

malities that contribute to lung cancer develop-

ment. This work has led to a novel therapy that

replaces defective genes in lung cancer cells

with normal functioning copies of the gene. This

work progressed from the laboratory to successful

clinical trials in a period of 20 years.5–7 Funding this

research was, and remains, a challenge and

involved obtaining grants from the NCI, founda-

tions, philanthropy, and industry. When designing

research protocols, it is important to let science

dictate the technique. Searching for applications

for techniques or devices rarely leads to conceptu-

ally significant results.

One of the most personally gratifying experi-

ences for me is acquiring new knowledge that

can benefit patients. Surgeon scientists have

contributed greatly to advancing scientific knowl-

edge and patient care. This career path is chal-

lenging and ultimately deeply rewarding.

VALERIE W. RUSCH, MD

Some surgeons seem to have followed a nearly

charmed path to academic success and interna-

tional renown. They are often the beneficiaries of

outstanding residency programs and excellent

mentoring, and seem to have had great wisdom

early on about their career development. For

various reasons, including the paucity of senior

women thoracic surgeons when I was training,

my career path has developed through patience,

persistence, and fortuitous circumstances, with

both good and bad decisions. The academic

career advice that I give trainees is based on

nearly 30 years of these professional life lessons

and can be summarized in the following 8 points:

Select an Academic Focus

This should be a topic; a disease or a scientific

question that interests you the most. Achieving

international respect from your colleagues takes

years of effort and requires making a lasting scien-

tific contribution. You cannot achieve this unless

you are intellectually challenged by the topic. In

addition, the subjects on which you publish and

are deemed an expert will influence the scope of

your clinical practice. Consider this carefully as

you select your academic focus.

Acquire the Correct Skills to Pursue Your

Academic Focus, Even if this Requires Some

Retooling After the End of Clinical Training

For instance, it is fairly common for surgical resi-

dents to spend 2 years in the laboratory in the

midst of clinical training only to decide later on

that they prefer to be clinical investigators or

educators. They then start their careers without

the requisite skills for these career pathways.

Given a supportive division chief and the appro-

priate infrastructure, additional training leading to

a Master’s degree in fields such as clinical investi-

gation, biostatistics, or education can be com-

bined with starting a clinical practice and will

greatly enhance the productivity and skill sets of

a young academic surgeon.

Become a World’s Expert by Studying Your

Chosen Academic Topic to an Unparalled

Degree

Ask and answer fundamentally important and well-

designed research questions about your primary

area of interest. Do not publish trivia or superficial

studies. Do not allow yourself to become academ-

ically diffuse, publishing on such a wide range of

topics that you become the jack of all trades and

master of none. Apply to your research the same

drive for excellence that thoracic surgeons bring

to clinical care.

Build the Correct Infrastructure for Your

Research Because You Cannot Do it All

Yourself

Such infrastructure is more easily defined for labo-

ratory investigators where there are traditional

parameters for surgical fellows, laboratory techni-

cians, and postdoctoral scholars. Clinical and

translational investigators require different and

varied infrastructure such as data managers,

research nurses, and tissue banks.

Develop Collegial and Productive

Collaborations

Whether your research is clinical, translational, or

basic science, the best research these days is

multidisciplinary. Be inclusive and supportive of

your research collaborators, especially with

respect to publications and grants. Cross-

disciplinary research is interesting, fun, and

rewarding.

Building a Successful Career

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Seek Mentors

Peer review and senior advice is frequently helpful

and most senior academic physicians are de-

lighted to provide this. Mentors may be surgeons

but are also often found in other specialties or

even nonclinical settings.

Carefully Guard Your Most Precious

Commodity: Time

Balancing clinical care demands with academic

work and your personal life is extremely chal-

lenging and only becomes harder as you advance

in your career. Figure out what really matters to

you academically, create time for it, and do not

be afraid to say no to other demands on your

time, especially tangential administrative ones.

Develop 5-Year Plans

It is important to take stock every few years (and 5

is usually a good number) of what you have

accomplished and where you are heading.

Consider whether your goals and interests have

shifted. Plan for where you want to be academi-

cally in 5 years. Make midcourse corrections, but

systematically and strategically.

Developing a successful academic career is

difficult given today’s many competing demands

on every surgeon’s time. It is hard not to be over-

whelmed by the need to sustain a busy clinical

practice, by ever-increasing regulatory require-

ments and administrative tasks. Setting the

parameters that allow academic success through

meaningful contributions to our field is challenging.

It is hoped that some of these guidelines, garnered

through life lessons, will help younger surgeons

achieve their academic goals.

DAVID J. SUGARBAKER, MD

The path to establishing yourself as a general

thoracic surgeon is unique for every individual.

No single formula exists. Concrete factors that

influence the direction your career or practice will

take include geographic location, patient demo-

graphics, local competition, referral patterns, and

whether you are operating in an academic or

private setting. Although areas under your direct

control, like refining your craft and acquiring new

technical skills, may consume much of your time

when you are starting out, establishing yourself

as a leader is one of the best and quickest ways

to build a practice and effect change. When

patients and consultants need a thoracic surgeon,

they seek the local, regional, and sometimes

national leaders in the field. In this regard, it is

difficult to overestimate the value of being a

good communicator.

What are the elements of leadership in surgery?

Scientific advancement is certainly paramount, as

is identifying changes that will result in quality

improvements in services provided at your

hospital or medical center. Being willing to get

involved with hospital administration and the local

medical community is also key. The overriding

question you must ask yourself is “How can I, as

a thoracic surgeon, take action to initiate change

that will improve patient outcome?”

Leadership begins at the local level. Tiny steps

that initiate improvements in the delivery of

medical care in your local hospital or community

can lead to sweeping changes. Actions you take

may affect the physical outcome of your patients.

What can I do to avoid complications or enhance

therapy or improve my patient’s functional status

measures? Other actions may improve service

outcomes. These actions affect the physician-

patient relationship. Such actions are measured

in terms of satisfaction, and the benefits extend

to families, communities, other caregivers,

vendors, and employees. You might ask, “How

can I make changes that turn the experience of

being a patient or caregiver from a hassle to

a convenience?” Other actions important to the

modern era include cost outcome measures.

How can I reduce the cost of a clinical process

to make it more affordable for patients? How can

I stretch the health care dollar? How can I reduce

the overall financial burden of disease on the

health care system?

Leadership at the national/international level

relies on scientific advancement, multidisciplinary

collaboration, and participation with peers through

membership in professional societies. Scientific

advancement at the basic research level takes

time because of the complexity of the biologic

systems involved in the interpretation of disease

in this molecular-genomic-proteomic-informatics

era. In this regard, it is helpful to focus your efforts

on a particular thoracic disease or difficult clinical

problem. Become an expert. Establish a record

of excellence through the publication of your

ideas.

In our profession, we have all experienced the

unique benefits of mentoring. We can learn a great

deal from these relationships, whether you are the

mentor or mentee. You do not have to be in

academic practice to get involved in mentoring,

teaching activities, and CME. Medical conference

participation may arguably be more important for

individuals in private practice than staff surgeons

at an academic center where there is greater

exposure to interdisciplinary case conferences,

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teaching conferences, and lecture series. If you

are working with mentees in the academic envi-

ronment, as a chief or program leader, there are

several important goals to bear in mind. First,

you must help them develop their personal skills

by providing the necessary resources. Second,

you must guide them to find a clinical niche that

best matches their experience, skills, and interper-

sonal abilities. Third, you must help them identify

their academic niche. Where can they best apply

their knowledge? Where can they make a differ-

ence? What questions need an answer? Forth,

and most important, you must help them to define

the next step. What are your expectations of

them? What should they do to get to the next

step scientifically or personally? What is keeping

them from advancement or promotion?

In the end, we are all grounded by what we do in

the clinic and in the operating room for our patients

and their families. The decisions we make on

a daily basis are often difficult and demand prepa-

ration, attention to detail, patience, and sacrifice.

We cannot be afraid to make tough decisions or

take difficult stands. Our reward comes from

knowing that we have made an important contri-

bution, whether to science, surgery, or society.

MANOEL XIMENES III, MD, PHD, FACS

My first role models in surgery were my professors

of surgery at Ceara University School of Medicine

in northeast Brazil. My interest in thoracic surgery

began during my internship at Euclid General

Hospital in Ohio while watching 2 general

surgeons, Drs J.W. Coburn and Jorge Medina,

care for patients. After finishing my internship

and considering many options in both Canada

and the United States, I decided to train in the

Huron Cleveland Clinic Health System. During

my senior year as Chief Resident, I had the privi-

lege of meeting Dr John Storer, Head of Thoracic

and Cardiovascular Surgery. Dr Storer was a skill-

ful surgeon who taught me a variety of procedures

including valve replacements under extracorpo-

real circulation, peripheral vascular surgical

techniques, as well as bronchoscopy and arterio-

grams. Dr Storer also taught me how to start,

write, and publish a scientific paper involving clin-

ical case reviews and prize-winning basic science

work from the laboratory.8

On my return to Brazil, I worked at Federal

University of Rio Grande do Norte in Natal, RN.

In 1974, I became a full Professor of Surgery at

University of Brasilia and Head of Thoracic Surgery

at Hospital de Base of Federal District where I am

currently located. To date, we have cared for more

than 10,000 patients at both the private and public

hospitals. In my position as Professor of Surgery, I

was able to complete my PhD degree.

To learn and practice new techniques I visited

several medical centers including: TGH to learn me-

diastinoscopy with Dr Pearson and lung transplan-

tation with Drs Patterson and Cooper, University of

Michigan to learn transhiatal esophagectomy with

Dr Orringer, Maine Medical Center to learn lung re-

section techniques with Dr Hiebert and the Massa-

chusetts General Hospital to learn surgery of the

trachea with Dr Grillo.9,10 For more than 30 years, I

have attended the Toronto Refresher Course and

all the information obtained in these meetings has

been conveyed to allied health professionals, resi-

dents, and attending staff. I would also recommend

the postgraduation course at Oxford University,

England, as a source of good learning.11,12

In 1976, we established a training program in

general thoracic surgery and have graduated 27

thoracic surgeons thanks to our affiliation with the

University of Sa˜o Paulo. All of our residents are

encouraged to do research and write papers. To

date, our group has published 173 scientific papers,

3 textbooks, and 25 book chapters, and has given

1250 presentations at various surgical meetings.

Our residency program also has a strong commit-

ment to education, with most of our residents

completing a 3-month rotation at a major medical

center such as the TGH, Cleveland Clinic, and

Mayo Clinic. Our teaching program also includes

journal clubs and weekly grand rounds with case

presentations and didactic presentations.

At 65 years of age, I considered retirement;

however, 10 years later, I continue to perform the

same tasks that I am used to doing (ie, teaching,

operating on major cases, keeping long office

hours, and attending surgical meetings all over

the world). I also enjoy walking (no elevators) and

regular tennis and fishing.

In summary, if a young individual wants to

become a thoracic surgeon, my advice is to (1)

be prepared to deal with difficult cases, (2) love

the specialty, (3) be available to patients and

colleagues 24 hours a day, (4) pass on all the infor-

mation and share your experience, (5) be open

minded to learn from success and mistakes, (6)

read every day, and (7) recognize that it is time

to retire when you no longer are capable of doing

your everyday routine.

ANTHONY P.C. YIM, MD, FRCS, FACS

It is truly an honor to be asked to contribute to this

monograph as the only surgeon from Asia. I

received my medical education in the United

Kingdom and surgical residency in the United

States. I returned to Hong Kong in 1992 to

Building a Successful Career

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practice. This experience allowed me to gain first-

hand information on health care delivery in some

vastly different systems. I would like to offer the

following advice to our younger colleagues drawn

from my own experience.

Attention to Detail

If I have to single out 1 character to differentiate

a good technical surgeon from an average one,

attention to detail (almost to the point of obses-

sion) tops my list. For a technique-based specialty

like surgery, this is crucial to achieve consistent,

reproducible results. During residency, we were

exposed to a wide spectrum of perioperative

routines adopted by our attendings. Variations

breed selection. With time, we formulate our own

routine. However, learning does not and should

not stop after residency. The biggest enemy of

success is complacency. We must be reminded

not to let our best performance so far set the stan-

dard for the rest of our career.

Attention to detail also does not stop at tech-

nique. When you are treating a patient, you are

not just treating a disease, but a person (and

sometimes a family). Patients and their families

often take to heart every word we say to them. A

good surgeon is someone who does not only

know how to operate but also knows how to effec-

tively communicate with others.

Think Outside the Box

Cardiothoracic surgeons, by their nature and

training, tend to be conservative. We spend nearly

a decade of training to do just a few operations

well. We inherit a set of routines from our teachers,

and we tend to resist changes that, by their nature,

introduce an element of uncertainty to the

outcome. Although there is nothing wrong with

this approach from a purely technical standpoint,

this mindset does not prepare us well for a rapidly

changing world. We therefore must keep an open

mind to new ideas, even though they may seem

farfetched at first sight. A good case in point is

VATS lobectomy. Two decades ago, this was

a heresy. Today, it has become the approach of

choice for early lung cancer.13

It is important to look beyond our own field,

because the role of surgery as we know today

will change. MIS will become more refined, and

more procedures will become either catheter

based or endoscopy based. The boundaries

between surgery, interventional radiology, and in-

terventional endoscopy will eventually disappear.

Many medical specialties of today will be trans-

formed into the organ-specific, integrated disci-

plines of tomorrow.

Stay Focused

If you are pursuing an academic career, it is impor-

tant that you should stay focused on your area of

research. You should also collaborate with your

peers, both within and outside your field. Early in

my career, I saw the great potential of applying

the minimally invasive technique to the thorax,

which arguably is the most ideal body cavity for

this. During that time, several groups of surgeons

in the United States and Europe were pursuing

the same goal. It did not take long for me to get

to know each of these great individuals well, and

some of them remain close friends to this day.

We published together our collective experience,

and the initial success of my career owes a lot to

this collaboration. Within my university, we have

collaborated with departments outside surgery to

look at MIS from other perspectives, such as

with the Department of Physiology on immune

function, and the Department of Engineering on

virtual reality training modules. When you have

written more than 20 major publications on the

same theme, you will be recognized by your peers

as an expert in that field. Once you are a recog-

nized expert on 1 subject, it will be much easier

for you to expand your research scope into other

fields.

Watch Your Back

Whenever you become successful in your own

field, you are prone to become a subject of jeal-

ousy. There is an old Chinese saying, “Only the

fools don’t attract jealousy.” Your very existence

could be perceived as a threat to others (and not

only to your peers). This jealousy is human nature

and we are bound to face challenges. We should

be constantly reminded that our primary responsi-

bility is to our patients. Success is not only

measured by how smooth your career sails, but

by the tenacity and determination to rise again

after a fall.

SUMMARY

In conclusion, I would like to thank the contributors

of this article who have been recognized as

outstanding leaders in thoracic surgery. From their

own unique perspectives, they have each

provided valuable insights that are important in

developing a successful thoracic surgical career.

REFERENCES

1. Pearson FG, Fell SC, Lerut T. History and develop-

ment of general thoracic surgery. In: Patterson GA,

Cooper JD, Deslauriers J, et al, editors. Pearson’s

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thoracic and esophageal surgery. 3rd edition.

Philadelphia: Churchill Livingstone (Elsevier); 2008.

p. 6–8.

2. Roth JA, Fossella F, Komaki R, et al. A randomized

trial comparing perioperative chemotherapy and

surgery with surgery alone in resectable stage IIIA

non-small-cell lung cancer. J Natl Cancer Inst

1994;86(9):673–80.

3. Roth JA, Pass HI, Flanagan MM, et al. Random-

ized clinical trial of preoperative and postopera-

tive

adjuvant chemotherapy

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