The emergence of general thoracic surgery in North America as a surgical subspecialty distinct first from general surgery and then from cardiac surgery and congenital heart surgery occurred through dramatic and tumultuous changes that once threatened but ultimately strengthened the integrity of the discipline. The discipline evolved from general surgery in the early 1900's in response to chest morbidities prevalent at that time, primarily tuberculosis and World War I-related trauma. Hence, the systems established to guide thoracic surgery were shaped by general surgeons. War continued to play a role in shaping surgery. In the 1940s World War II required new strategies for management of injuries from new weapons. By the 1950s, new knowledge and technology began to lift the physical and psychological barriers to surgery within the chest, including the heart. The technical achievement of extracorporeal circulation by John Gibbon, first used in humans successfully in 1953, allowed the extension of cardiac and congenital heart surgery into more complex problems and ultimately new fields of specialization in myocardial revascularization, valve surgery, and heart transplantation in the late 1960s. These changes occurred as antibiotic use reduced the incidence of tuberculosis and the need for pulmonary surgery. Soon, combined cardiothoracic surgery programs began to form.
The union between thoracic and cardiac surgery, however, was not altogether ideal, and thoracic training often played second fiddle to cardiac training. In 1981, Donald Paulson, President of the American Association for Thoracic Surgery, focused on the inadequacy of training in general thoracic surgery. In his presidential address, he stated: “Failure to correct the imbalance in training of thoracic surgery has resulted in a vacuum, which could lead to disintegration of the specialty.”1 By the 1990s, the realm of general thoracic surgery was so eclipsed by the dramatic developments in cardiovascular disease that funding in combined cardiothoracic programs began to be diverted in favor of cardiac training.
This pattern was played out largely in the U. S., United Kingdom, and Europe, and threatened the ability of such programs to attract top-notch general thoracic surgeons. In an editorial symposium published in 1991 in the Annals of Thoracic Surgery, the President of the American Association for Thoracic Surgery, John Waldhausen, addressed the broad concern that American thoracic surgery programs were failing to attract the “brightest candidates.” Later that year, an educational workshop was convened in Snow Bird, Utah, to define the deficiencies in American thoracic surgery.
Meanwhile, although similarly influenced by the pace of development in cardiac and congenital heart surgery, events transpired somewhat differently in Canada. In the early 1950s there were three divisions of general surgery in Toronto. Thoracic and cardiac surgery were practiced as subspecialties in each of these divisions. In 1953, Wilfred Bigelow was appointed to head one of the three divisions. A general surgeon by training with an interest in vascular and cardiac disease, but no training or interest in thoracic procedures, Bigelow proposed a separate division, training program, and certification ...