Le t t e r s to the E d i t o r

Short preceptorships for postgraduate training in new techniques

To the Editor: A major failing of postgraduate medical education is that

there is very little opportunity for a physician to learn new techniques in a short, formal, teaching program, once he has finished his fellowship. There are abundant seminars, medical meetings, cassette tape transcriptions of lectures, a n d other such modalities for teaching theoretical concepts. However, the academic community has not provided satisfactory ways for the physician or surgeon to learn new techniques. For example, in the past 15 years in Cardiology alone, Echocar- diography, Exercise stress electrocardiography, Swan-Ganz catheterization, the passage of an emergency transvenous pacemaker, His electrography, the rendering of the entire spectrum of critical care medicine in a coronary care unit, DC defibrillation, Holter monitoring, the emergency introduction of an intra-aortic balloon for cardiogenic shock, e t c . . , all have become important techniques in the practice of Cardiol- ogy. Yet, even for those of us connected with a university teaching center, gaining actual experience in these techniques is difficult. For the majority of physicians not so academically connected, the problem is compounded a hundredfold.

Surgeons have similar difficulties in learning new operative procedures, and. because of the nature of their work, this defect in their postgraduate education is even more serious than in the case of internists and pediatricians. Those surgeons that I have questioned confide that if they are to gain such experience in new techniques at all. they do so by surreptitiously "scrubbing-in" with a friend who is adept at performing the new procedure, or. if this is not possible, by simply trying out the procedures de novo on their own patients. For example, almost all present day colonoscopists are self-trained: they simply buy the instrument and try it out on their patients. Cardiac surgeons who graduated as recently as 10 years ago have learned the new techniques of coronary venous bypass surgery by similar dubious methods. Estab- lished orthopedic surgeons implant prosthetic knees and hips with knowledge gained by reading about the techniques in a journal, or by the "'see one-do one" method. Obviously. such solutions are ethically unacceptable, and have explosive potential for medico-legal disaster, particularly in the present litigious climate of society.

My suggestion for a more satisfactory solution to this problem is a series of full time, 1 to 4 week Preceptorships at a major medical center. The physician or surgeon would work full-time at the institution during this period, a time interval that most physicians or surgeons could afford co take off from their practices or university positions. For the more commonly performed new techniques, the physician or surgeon should be able to acquire a reasonable amount of expertise within this period of time, particularly if the university hospitals make it a point of concentrating their elective cases involving this procedure within this teaching interval. For the less common procedures, or for the procedures done only randomly at the time of an emergency, a student-specialist might have to return for a repetition of the course two or three times over a period of a year or two to gain adequate expertise. With adequate record-keeping of the student's progress, such cumu-

lative experience could be had in different institutions at the student's convenience.

I would also recommend that each teaching department apply to the appropriate certifying organization-American College of Cardiology, American College of Surgeons, etc .-for official approval of these courses, and that, after the successful completion of these courses, an officially s tamped certifying diploma be given to the candidate. This would carry great weight, not only in a court of law, but with the administra- tions of the community hospital where the physician or surgeon may want to introduce the new procedure,

I predict that the introduction of such a program would elicit an enormously popular response from all over the country.

Myron R. Schoenfeld, M.A., M.D., F.A.C.P. 2 0 v e r h i l l Road

Scarsdale, N.Y. 10583

TAPVC vital statistics: Ethics and moral values

To the Editor: It is obvious that Dr. Bharati's article 1 is the largest series of

TAPVC'S dealing only with morbid pathological anatomy and Dr. Van Praagh's excellent review ~ is the largest series of diagnostic and surgical aspects of TAPVC.

The point I would like to make is that a research trainee need not feel frustrated :~. 4 if her (or his) work is not included or quoted in the bibliography. It is entirely up to the author's discretion, individual judgment, and free decision to quote and select reference articles of inherent worth and intrinsic value pertaining to his subject matter. I t is his prerogative to separate the chaff from the grain. A n d this is the basic to all aspects of scientific publications.

A research trainee need not expect other workers to be all- embracing in choosing references and bibliography. The day of the "learned review" is almost over. The year books which exist in almost every subject now subserve this function. In general the best original papers have the fewest references.

Internal anxiety about non-recognition of one's own work should not be projected and distorted as a phoney concern about a "chance reader getting erroneous ideas. ''3

Allen Rathnam, M.D. Chief, Unit 98

Veterans Adminis trat ion Hospital Danville, Ill. 61832

REFERENCES 1. Bharati, S., and Lev, M.: Congenital anomalies of the

pulmonary veins, Cardiovasc. Clin. 5:23, 1973. 2. Delisle, G., Ando, M., Calder, A. L., Zuberbuhler, J. R.,

Rochenmacher, S., Alday, L. E., Mangini, O., Van Praagh, S., and Van Praagh, R.: Total anomalous pulmo- nary venous connection: Report of 93 autopsied cases with emphasis on diagnostic and surgical considerations, AM. HEART J. 91:99, 1976.

3. Bharati, Saroja: TAPVC vital statistics (Letter to Editor), AM. HEART J. 92:410, 1976.

4. Van Praagh, R.: Reply (Letter to Editor), AM. HEART J. 92:410, 1976.

6 7 6 M a y , 1977, Vol. 93, No. 5