The European Society of Thoracic Surgeons (ESTS) post-graduate course (PGC)
Commensurate with the rise of China as a nation, the clinical and academic standards of thoracic surgery in China have also advanced remarkably rapidly in recent years. As thoracic surgeons from China seek to gain international recognition for their expertise and experience, forging relationships with the foremost professional societies in the specialty is an integral step.
In terms of professional societies, few are as important to this specialty as the ESTS. The ESTS is currently the largest association of general thoracic surgeons in the world, and its annual European Conference on General Thoracic Surgery is also the largest scientific meeting in thoracic surgery in the world today. The ESTS establishes guidelines for the practice of thoracic surgery in Europe, certifies centers in thoracic surgery for institutional quality, and also participates in the regulation of examinations and training standards in the specialty across Europe. It engages in education through the ESTS School, multiple courses on clinical and academic skills throughout the year, and publication of its own textbook on thoracic surgery. Importantly, it also runs the ESTS Surgical Database—one of the most important clinical databases in thoracic surgery in the world.
Amongst the most important events run annually by the ESTS is the PGC. The PGC is a one-day event held each year on the Sunday prior to the commencement of the annual European Conference on General Thoracic Surgery. As its name implies, the aim of the PGC is to provide education and clinical knowledge updating for all members of the ESTS and attendees of the European Conference on General Thoracic Surgery. Providing the content of the PGC are renowned senior members of the ESTS and internationally recognized surgeons who are friends of the ESTS, ensuring the highest possible quality of the information shared.
Many cardiothoracic surgery associations nowadays run similar post-graduate education events. However, what makes the ESTS PGC special is the format. In the past, the ESTS used to run the PGC in a similar way to other associations: using a series of invited ‘expert lectures’. This traditional format proved not only staid and uninteresting, but it also proved to be a relatively inefficient way of educating. Several years ago, therefore, the ESTS changed to a highly original debate format for the PGC. Three teams of top surgeons from Europe, America and Asia respectively would compete in three-way debates over a topic of controversy in thoracic surgery. Each team would be allocated to argue in favour of one viewpoint in the controversy, and the team that converted most audience members to their viewpoint would win that particular debate. Topics in the past have included: the best surgical approach for managing a traumatic hemothorax, management of post-operative air leaks, and so on. The team that won the largest number of individual debates would win the prestigious ESTS Masters Cup for that year. The debates proved very popular: they were friendly and humorous, and they managed to both educate and entertain the audience at the same time. Education through expert arguments on these thought-provoking topics seemed a wonderful way to advance post-graduate education. Nonetheless, there were two problems. First, the fact that a team debated well and won an argument did not necessarily mean that their viewpoint was clinically the most ‘correct’—an objective ‘best’ answer was not provided after a debate. Second, the audience may have enjoyed the debate, but may also have felt that they were unable to participate or contribute to the discussion.
Therefore, in 2014, the format of the PGC was further updated by the ESTS. Now, instead of a debate, the PGC has become a question-and-answer competition. Each team would take turns to ask the other two teams a series of multiple-choice questions on a challenging clinical scenario. In each of the competing teams, trainee members and the senior member (renowned surgeons of that continent) could discuss the answer, and the audience could also participate actively in providing an answer. Once the teams have declared their answer, the one correct answer would be revealed—along with a clear evidence-based explanation of why that answer had to be the correct one. This new format proved successful at the ESTS 2014 PGC in Copenhagen, and has helped the ESTS PGC remain arguably the most exciting and highly-regarded PGC in cardiothoracic surgery today.
In the 2015 European Conference on General Thoracic Surgery in Lisbon, the PGC will continue in this format. However, under the new organizers—Dirk van Raemdonck and Alan Sihoe—there will be further modifications to enhance audience participation and interest. Amongst the breakthroughs will be—for the first time—use of an App on each audience member’s own smartphone or tablet computer that will allow the audience to voice their opinions and vote on answers during each question. The competition for the Masters Cup should prove to be more exciting and rewarding than ever before!
AME: bridging the distance between China and the ESTS
The ESTS has long shed its role as a Europe-only association. Nowadays, half the participants at each annual European Conference on General Thoracic Surgery come from outside Europe, especially from North America and Asia. Over the last several years, the participation from Asian surgeons in presenting abstracts, videos and posters has been expanding strongly. Indeed, many prizes at the 2014 European Conference were actually won by Japanese surgeons—including the highest award issued by the ESTS: the Brompton Prize. However, notable amongst the great turnout by surgeons from Japan, Korea, India, and other Asian countries was the relative lack of surgeons from China. Whether it is because of lack of confidence, understanding about the meeting, or English skills, it seemed that Chinese surgeons had not yet found the impetus to come to this most important of all general thoracic surgery meetings.
In recognition of this, a strong effort has been launched to bridge the distance between China and the ESTS. As said before, Alan Sihoe is co-organizing the PGC this year, and has secured greater representation of Chinese surgeons in the Asia Team this year. Alan Sihoe has also teamed up with Dr. Lunxu Liu of West China University to organize a Joint Session of the ESTS and the Chinese Association of Thoracic Surgeons at the 2015 European Conference on General Thoracic Surgery in Lisbon. Throughout the year, ESTS senior members have also been welcomed to many meetings and events in China, including the 2014 Shenzhen Surgical Forum and the 1st China (International) Single Port VATS Symposium in Shenzhen in 2014. As greater appreciation of what the ESTS has to offer is gained, increasing numbers of Chinese thoracic surgeons have chosen to join the ESTS as active or trainee members.
Making a hugely significant contribution to this East-West connection has been AME Publishing. AME has promoted many of the above events, and has extensively covered the interactions between China and Europe through their news coverage, publications and social media. Importantly, AME will this year work directly with ESTS in sponsoring the PGC. Dr. Stephen Wang of AME has generously agreed to sponsor two big prizes during the PGC. First, there will be an audience prize. The audience at the PGC will be allocated randomly using the App to support one of the three competing teams. The audience can help provide comments and tips for the team they support during the PGC, and if their team wins then all audience members supporting that team will win a small prize. Hopefully, that will stimulate the audience to really support their team! Second, the junior (trainee) member that has given the best overall performance in the PGC will win an all-expenses-paid attachment to a leading thoracic surgery unit in China! These prizes are unprecedented in the ESTS, and should help elevate the PGC to become an even more attractive international event.
The AME Special Competition
As part of AME’s efforts to boost Chinese participation in the PGC and enhance collaborations between ESTS and thoracic surgeons in China, Dr. Stephen Wang initiated the idea of the AME Special Competition 2015. The aim of this competition was to select Chinese trainee thoracic surgeons who could represent China in the Asia Team at the PGC in Lisbon in 2015. There will be a total of six trainee members in each of the European, American and Asian teams at the PGC (in addition to six senior surgeon members). The two top contestants in the AME Special Competition would be nominated to the Asia Team captain—Prof. Jheon Sanghoon of Korea—for consideration of inclusion in the team.
The AME Special Competition was held in four cities in China: Fuzhou, Shanghai, Chongqing, and Beijing. At each city, 5-10 contestants were entered in the competition. In total, 27 contestants participated in this very special event held across four cities (Figure 1). Each contestant must be eligible and have applied to be a trainee member of the ESTS before they could be considered for the Asia team. The leading thoracic surgeons from each city and its surrounding region were invited by AME to be mentors for the contestants (Figure 2).
The format for competition at each city was the same. To simulate the actual situation at the PGC, the entire competition was conducted in English. In the first round, each contestant was invited on stage to ask a multiple-choice question based on a challenging clinical scenario according to the style of the ESTS PGC. The other contestants then had a minute to discuss the correct answer with the mentor(s) assigned to him/her. During this time, the audience could freely give comments and opinions to participate in the discussion. At the end of that minute, each answering contestant gave their answer, explaining why they chose that answer. Once all contestants had done so, the asking contestant revealed the correct answer, providing evidence from the literature that supported that being the correct answer. The audience also had the opportunity to vote for their own choice of correct answer.
Once all the contestants had the opportunity to ask their prepared question, the competition entered the Second Round. In this round, Dr. Alan Sihoe and Dr. Stephen Wang asked each contestant a simple question. This question may or may not have been related to thoracic surgery. The contestant answered the question in English. The object was not to give a ‘correct’ answer (as no such answer may have existed). Instead, the question was meant to test the contestant’s reactions and ability to improvise and deliver an audience-friendly response on stage whilst under pressure. This is a characteristic that is often very important when presenting at international conferences, and one is asked challenging questions from the audience or session chairpersons. If a trainee from China was to join the Asia team, it would have been important to select someone with good stage presence, confidence, and ability to connect with a demanding audience.
After the two rounds were completed, the audience and mentors were separately invited to vote for which contestant they felt could best represent China in the Asia team. The contestant at each city with the highest audience vote total receives a prize (Figure 3).
The contestants were also judged and scored separately by Dr. Wang and Dr. Sihoe. This confidential scoring was taken into account in determining the best contestants after the competition in all four cities was finished. The top contestants from each city were invited to a special Presentation Ceremony in Guangzhou. At this ceremony, all these top contestants received a certificate and a special prize from AME. The top two contestants overall were also announced. This year, Dr. Azmat Rustam and Dr. Xinghua Cheng were the eventual ones nominated to Prof. Jheon for consideration of inclusion to the Asia team at the PGC (Figure 4).
For all contestants in all the four cities, feedback was also provided on their performances. On the day of the competition, the mentors could directly report on the contestants’ performances. Subsequently, Alan Sihoe also wrote privately to every one of the contestants, giving details about how they performed and giving advice on how to improve in their future presentations. It was hoped that this private mentorship could help these young surgeons’ future careers, and should be a fitting reward for their enthusiasm in joining the AME Special Competition.
Lessons learned from the contestants
It is fair to say that the contestants all enjoyed the AME Special Competition, with its friendly atmosphere and a warm environment to practice public speaking. However, besides gaining learning, the contestants were also able to teach a number of very valuable lessons to everybody present—this author included.
The first lesson was the pleasant surprise that young surgeons in China could generally speak English quite well. It is a simple fact that English remains—for the foreseeable future at least—the international language of medicine and science. If Chinese surgeons are to be accepted into the wider world of thoracic surgery globally, it is still necessary to communicate with peers around the globe using English. In this regard, it was great to see that all 27 contestants could communicate in English, and express themselves intelligibly. Obviously, the standard of English varied. On one end were some whose spoken English was still hesitant and accented, and at the other end were those who were so fluent they could easily be mistaken for having been born and raised in America or England. However, in all cases, the English was good enough that if they were to present at an international meeting, their message would be understood by the audience. There are certainly many Europeans and Asians whose English may not have been as good.
The second lesson was that—language aside—the presentation skills of some contestants were also fairly good. From basic design of PowerPoint presentations to their bearing on the stage, there were some candidates who appeared genuinely confident and comfortable on stage. It is very important at conferences to display confidence and an audience-friendly manner when presenting (Figure 5). This helps the speaker connect with the audience, and allows it easier for them to understand and appreciate the message being delivered.
The third lesson was that the surgical knowledge and grasp of the literature of the candidates was also very good. This lesson was perhaps the least surprising. Chinese students have always been known for their excellence at learning and studying. This was demonstrated by the contestants’ well-designed questions, and very clear explanation of the correct answers using the literature well. When discussing answers to the questions of others, the contestants were also able to generally give well-reasoned and logical explanations of their choices of answer. This ability to use knowledge showed a pleasing ability to ‘think on one’s feet’ which is important to making good presentations at scientific meetings.
Obviously, besides the good points were some areas where the contestants showed there was room for improvement.
Some (not all) contestants had still not fully grasped the importance of audience interaction. Their presentations were delivered looking down into their notes. Their answers to questions were directed only to the person asking, or—even worse—to the projector screen on stage. In most cases, the key problem was the same: they failed to make eye contact with the audience. When speaking at an international meeting—whether presenting an abstract or speaking at a PGC—it is important to remember that the audience is the most important subject. If one fails to engage and interact with the audience, the audience will switch off and disengage with the speaker. In that case, no matter how good the content of the speech, the message would not have been well received and appreciated and the presentation may not have succeeded. It would appear that for some contestants at this AME Special Competition, this lesson has not yet been learned. However, with the experience gained here, and with the reports given by the mentors and Dr. Sihoe, it is hoped that they can improve in future.
It was also noted that some contestants were not engaging with their mentors very well. One of the key elements of attending a conference is the chance to interact with other presenters and delegates to share ideas and experiences. The interaction within the teams and with the audience during the PGC at the ESTS meeting is a classic example of this, with the discussion being educational and helpful to all. Without such interaction and discussion, attending a meeting would be no better than reading a paper at home. With this in mind, it is always good to see many of our young contestants being able to engage with their mentors and even with the audience in discussion. For those who did not do so well in this area, it is hoped that the experience from this AME Special Competition would spur them on to ‘loosen up’ and be more ready to communicate with others around them during any meeting.
It was also noted that some contestants had prepared for the meeting better than others. Some candidates had not rehearsed as well, and some were even improperly dressed for the occasion. It is often key to a successful presentation to prepare well. That includes finding out beforehand what to expect: what audience would be present; what slides are expected; how much time has been allocated for presentation; and—yes—what the dress code is. Inadequate preparation can ruin the presentation of a very good piece of research. For those contestants who perhaps did less well in this regard, it is hoped that the opportunity to observe how other contestants performed would be a valuable lesson in how to prepare in future.
In summary, the contestants showed us how surprisingly good our young Chinese trainee surgeons can be when presenting on the stage at a meeting. The future looks very bright indeed. There are certainly areas for improvement, but it is through participation in events such as the AME Special Competition that the experience can be accumulated to trigger such improvements.
Lessons learned by the audience
Through this AME Special Competition, it is genuinely hoped that not only the contestants, but also the audience had the opportunity to learn something about international meetings such as those held by the ESTS.
The most immediate lesson that the audience should have appreciated was how effective the ESTS PGC format is in providing education and clinical knowledge updating in a fairly entertaining and engaging manner. By making this a competition, there is an ‘edge’ to the event, and there is more sense of importance in knowing what the answers are. Because the audience is invited—even encouraged—to take part in the whole discussion, they too become stake-holders like the teams competing. When the realization that the questions and answers are going to be provided by leading surgeon experts is also factored in, then there is also an assurance of the quality of education provided. It is hoped that this will help demonstrate to surgeons in China why it is so worthwhile attending the PGC at the annual ESTS meeting!
The next very important lesson is the lesson of the relevant clinical question. The PGC could have been conducted like many meetings held in China: with a series of lectures by ‘experts’. However, this one-directional, non-interactive method of information delivery is potentially boring and may not interest audiences enough to hold their attention. Instead, if knowledge is imparted in a ‘problem-solving’ manner, by framing a real-life clinical scenario and asking a clinically relevant question about it, then the use of knowledge to solve the question renders that knowledge more vivid and important. By regarding each question asked and then thinking about the correct answer, the contestant and audience alike can see the implications and relevance of the knowledge. This is a vital lesson that may help medical writing by many colleagues in China. Too often, clinical research papers from China are being rejected by international journals because they simply report results of a large case series. This is similar to an ‘expert’ lecturing: it is one voice talking blandly about a subject. The trick to acceptance of a paper can often lie in using the knowledge and experience from such a large case series to answer a relevant clinical question. If the authors can identify a relevant clinical scenario or problem, and then apply their case series data to show how that problem can be solved, then suddenly the paper that results can be of interest to readers and may be accepted by readers. In this way, a change to this PGC-style of meeting (moving away from one-directional lecturing) can change views on how to use knowledge and data, and this may ultimately prove very helpful in training Chinese surgeons how to write better research papers in future.
A third valuable lesson for the audience is to see how high the standards of presentation by our junior surgeons are. It is enormously important for senior surgeons to lecture to share their experience by continuing to deliver traditional lectures. However, it is clear that much of the leading clinical research will come from the ambitious younger generation, daring to think outside the box. It is also evident that many of them will be able to present such exciting new research using styles and skills that are beyond many of us of the ‘older’ generation. Many of the contestants in this AME Special Competition have dazzlingly demonstrated that our future is in good hands, and that they are quite capable of delivering great presentations on the international stage. It is important that we nurture their budding talents, and help guide them to take the reins as surgery and surgical research moves forwards. One of the best ways to do this is simply to provide them the opportunities to present more. Whether it is participating in the PGC, presenting an abstract at the ESTS meetings, or even delivering a talk at an AME-organized event, it is the accumulation of hands-on experience at scientific presentations that will best hone their skills and shape their confidence.
If there is any one thing made clear during the course of this AME Special Competition, it is that this cannot be allowed to be a one-off event. This competition has provided young surgeons with an invaluable learning experience—almost a simulation of the actual PGC and of being at an ESTS meeting. It has hopefully opened up the eyes of many in the audience to a new style of academic meeting in thoracic surgery—moving away from didactic lecturing to a more interactive, problem-solving setting that is both educational and entertaining. And it has certainly helped bring many thoracic surgeons in China closer to international associations like the ESTS, which should help them integrate better with international standards of academic exchange. Because of these benefits, events like this AME Special Competition need to be perpetuated.
The future of these events requires support. It certainly needs the support of far-sighted sponsors such as Dr. Stephen Wang and AME Publishing. But more importantly, it requires the support of the thoracic surgery community as a whole. The community needs to appreciate the lessons learned as above, and to see the value of holding such events and meetings. It needs then to support these events whenever they are held—not only by attending, but by encouraging their trainees to attend also, and to actively interacting at the events. The magic of these international-style meetings happens when there is interaction from everyone: speakers, chairpersons, and audience members. Speaking up and not being shy is probably the best way to show one’s support.
This author wishes to thank AME Publishing, the sponsors Covidien/Medtronic, the many friends and senior surgeons at each of the four cities this AME Special Competition was held in, all 27 wonderful contestants, and of course everyone who attended in the audience. The entire event has left many fabulous memories. The author looks forward to meeting you—the reader—at a future event and creating new memories.
Disclosure: The author declares no conflict of interest.