Thoracic Surgery Training Programs Research Articles

Comparing Match Outcomes in a Surgical Subspecialty: Independent Versus Integrated Training Pathways

In recent years, the Thoracic Surgery Match (TSM) has become increasingly competitive. The purpose of this study was to compare recent trends in application and match rates in the TSM by training pathway. This was a retrospective cohort study of all applicants to Integrated and Independent pathways for Thoracic Surgery training (2008-2021). Chi square tests were used to elucidate temporal trends and make comparisons by training pathway. Accreditation Council for Graduate Medical Education (ACGME)-accredited Thoracic Surgery training programs in the United States. 1500 Independent and 1242 Integrated pathway applicants for Thoracic Surgery training. From 2008 to 2021, the annual match rate decreased from 91% to 71% in the Independent pathway (p < 0.001). This was driven by a decrease in the number of training positions (130-101, 22% decrease) and increase in number of applicants (96-140, 46% increase). In the Integrated pathway, the annual match rate increased from 33% to 35% (p < 0.001) as did the number of training positions (3 to 46, 1430% increase) and applicants (9-129, 1333% increase). During each year, match rates in the Independent pathway exceeded those in the Integrated pathway (p < 0.001). U.S. Allopathic graduates had higher match rates than non-U.S. Allopathic graduates for both Integrated and Independent training pathways. The percentage of applicants in the Independent pathway matching at one of their top 3 choices decreased from 73% to 40% (p < 0.001). The percentage of Independent thoracic surgery training positions that went unmatched decreased from 28% to 2% (p < 0.001). This percentage was stable at an average of 1% in the Integrated pathway (p > 0.05). The TSM has become increasingly competitive for Independent pathway applicants and remains ultracompetitive for Integrated pathway applicants. More research is needed to understand disparities in match rates by Thoracic Surgery training pathway.

Critical Comparison of the Quality and Content of Integrated Vascular Surgery, Thoracic Surgery, and Interventional Radiology Residency Training Program Websites: Qualitative Study.

BackgroundWith the move to virtual interviewing, residency websites are an important recruitment resource, introducing applicants to programs across the country and allowing for comparison. Recruitment is highly competitive from a common potential pool between vascular surgery, thoracic surgery, and interventional radiology with the ratio of applicants to positions being highest in interventional radiology, followed by thoracic surgery and lastly vascular surgery, as reported by the National Resident Matching Program.ObjectiveThe aim of this study is to evaluate the accessibility and availability of online content for those integrated residency programs.MethodsA list of accredited vascular surgery, thoracic surgery, and interventional radiology residencies was obtained from the Accreditation Council for Graduate Medical Education (ACGME) database. Program websites were evaluated by trained independent reviewers (n=2) for content items pertaining to program recruitment and education (scored absent or present). Statistical analysis was performed in R software.ResultsOf ACGME-accredited programs, 56 of 61 (92%) vascular surgery, 27 of 27 (100%) thoracic surgery, and 74 of 85 (87%) interventional radiology programs had functional websites (P=.12). Vascular surgery websites contained a median of 26 (IQR 20-32) content items, thoracic surgery websites contained a median of 27 (IQR 21-32) content items, and interventional radiology websites contained a median of 23 (IQR 18-27) content items. Two content items considered highly influential to applicant program decisions are procedural experience and faculty mentorship, which were reported at 32% (18/56) and 11% (6/56) for vascular surgery, 19% (5/27) and 11% (3/27) for thoracic surgery, and 50% (37/74) and 15% (11/74) for interventional radiology (P=.008 and P=.75), respectively. Key deficits were work hours, debt management, and curriculum for interventional radiology; resident profiles, sample contracts, and research interests in vascular surgery; and operative experiences and the program director’s contact and message for thoracic surgery. Interventional radiology deficits were work hours, and thoracic surgery deficits were procedural experience. Both interventional radiology and thoracic surgery websites lacked information on evaluation criteria and faculty mentorship.ConclusionsThis study has uncovered key differences in the availability of online content for residencies recruiting from the same pool of applicants. Thoracic surgery has the most information, followed by vascular surgery, with interventional radiology reporting the least content. In the era of virtual interviewing from the same potential pool of applicants, programs should review and revise their web presence with the aim to increase the availability of online content to attract valuable candidates.

The Thoracic Surgery Medical Student Association: Understanding the needs of medical students pursuing cardiothoracic surgery in the United States

ObjectiveFounded in 2020, the Thoracic Surgery Medical Student Association is the first national organization dedicated to supporting medical students interested in pursuing cardiothoracic surgery. Our inaugural survey aimed to describe their basic characteristics and needs. MethodsAn Institutional Review Board–approved, nonincentivized, anonymous electronic survey was distributed to any medical students enrolled in Liaison Committee on Medical Education–accredited medical schools through social media such as Twitter, national organizations (Association of Women Surgeons, Thoracic Surgery Resident Association), and medical school cardiothoracic surgery interest groups. Their basic characteristics, attitudes, and preferences regarding cardiothoracic surgery were recorded. ResultsOf the 167 students from 117 unique schools who completed the survey, 53% identified as White and 57% identified as female. Stages of training were well distributed: 16% first-year medical students, 33% second-year medical students, 16% third-year medical students, 21% fourth-year medical students, and 14% dual degree/research students. Most participants (57%) did not have (32%) or were not aware of having (25%) a thoracic surgery training program at their home institution. The majority (72%) of students reported not having a cardiothoracic surgery interest group at their home institution. The most desired areas of cardiothoracic were networking (31%) and mentorship (28%). ConclusionsThere is a significant need to directly engage medical students who are interested in cardiothoracic surgery considering limited exposure at home institutions through a lack of cardiothoracic surgery interest groups and cardiothoracic residency programs. The Thoracic Surgery Medical Student Association is poised to address these areas with directed networking by connecting cardiothoracic surgery faculty and residents from other institutions with medical students interested in pursuing cardiothoracic surgery.

Insights from the thoracic surgery residents association early-career development series

Insights from the thoracic surgery residents association early-career development series

Cardiothoracic Surgery Training Program Director Awareness of Available Visiting Medical Student Clerkships for the Underrepresented in Medicine

A diversity gap exists within cardiothoracic (CT) surgery that might be addressed with currently available medical student pipeline programs. We sought to assess CT surgery residency/fellowship program directors' (PD) awareness of and participation in underrepresented in medicine visiting medical student clerkship programs (UIM-VMSCPs). We reviewed the ACGME program finder database and medical school websites to identify thoracic surgery training programs that: (1) offer visiting student clerkships (VSCs), (2) are affiliated with an institution offering a UIM-VMSCP, (3) are at an institution where the existing UIM-VMSCP specifically offers rotations in CT surgery. The PDs in the second group were surveyed via e-mail, assessing their level of awareness of UIM-VMSCPs at their institution, participation in UIM-VMSCPs over the past 3 years, and desire to participate in a UIM-VMSCP in the future. All (n=76) ACGME CT surgery training programs were affiliated with institutions that offered VSCs in multiple disciplines. Over half, 55.3%, of the programs offered access to visiting students and 61.8% were at institutions with existing UIM-VMSCPs. Our response rate for the 47 PDs from institutions with UIM-VMSCPs was 38.2%. Of the respondents, 61.1% were aware of the UIM-VMSCP at their institution and 44.4% participated in the past 3 years. Most, 88.9% were interested in participating in their institution's UIM-VMSCP in the future. Only half of CT surgery training programs offer VSCs and even fewer are at institutions with an existing UIM-VMSCP that offers a CT surgery clerkship. This is a lost opportunity to broaden exposure to the specialty and increase diversity within the CT surgery workforce.

Coronary Anastomosis Simulation: Directed Interventions to Optimize Success

The role of simulation-based training in coronary artery bypass grafting remains undefined. Barriers to simulator use include clinical and personal obligations, insufficient materials, and lack of mentorship. The purpose of this study was to implement a longitudinal, residency-wide coronary anastomosis simulation curriculum. A prospective observational study was conducted from 2018 to 2019 at a single academic center. All residents of the Thoracic Surgery training program participated. Each participant was provided a low-fidelity coronary anastomosis simulator, high-quality instruments, and faculty mentor. Formal assessments were held quarterly, and residents were encouraged to practice alone and with their mentor. Baseline and follow-up metrics were compared with simple descriptive statistics. Seventeen residents and 12 faculty participated in the study. Residents demonstrated increased use of the simulator, with 21% participating in independent practice at baseline and 82% in the fourth quarter (P= .02). The median score on the Thoracic Surgery Directors Association Vessel Anastomosis Assessment improved from 42 out of 65 at baseline to 54 out of 65 in the fourth quarter (P= .04), and mean anastomosis time was reduced by 5 minutes 6 seconds (P= .02). Over 12 months, junior residents demonstrated a mean reduction in anastomosis time of 6 minutes 36 seconds, and senior residents decreased anastomosis time by 3 minutes 6 seconds (P= .02). Providing residents with a low-fidelity coronary anastomosis trainer with high-quality instruments and a faculty mentor improved rates of independent practice, Thoracic Surgery Directors Association assessment scores, and anastomosis time. Our next step is validating the coronary simulator curriculum by measuring improvement of resident performance in the operating room.

An Evaluation of the Availability and Accessibility of Online Content of Integrated Vascular Surgery, Interventional Radiology, and Thoracic Surgery Training Program Websites for Residency Applicants

Residency websites are an important recruitment resource, introducing applicants to programs across the country and allowing for comparison. Recruitment is highly competitive between vascular surgery (VS), CT, and interventional radiology (IR) with the ratio of applicants to positions being highest in CT, then IR, and last VS, as reported by the Electronic Residency Application Service. Thus, we sought to evaluate the accessibility and availability of online content for those integrated residency programs. A list of accredited VS, IR, and CT residencies was obtained from Accreditation Council for Graduate Medical Education. Program websites were evaluated by independent reviewers for content items pertaining to program recruitment and education (scored absent or present). Statistical analysis was performed in R. Of Accreditation Council for Graduate Medical Education-accredited programs, 74 (87%) of 85 IR, 56 (92%) of 61 VS, and 27 (100%) of 27 CT had functional websites. IR websites contained 19.4 ± 9.54 (mean ± SD) content items (interquartile range [IQR], 14.8-25.1), VS websites contained 24.2 ± 10.7 (mean ± SD) content items (IQR, 19-31.5), and CT websites contained 26.6 ± 7.15 (mean ± SD) content items (IQR, 21.8-31.5). CT and VS websites contained significantly more content items than IR websites (P = .0004 and P = .0026, respectively). Two content items highly influential to applicant program decision are operative experience and faculty mentorship, reported at 50% and 14.9% for IR, 32.1% and 10.7% for VS, and 18.5% and 11.1% for CT. Key deficits were work hours, debt management, and curriculum for IR; resident profiles, sample contract, and departmental research interests for VS; and operative experience, PD contact, and message for CT. IR deficits in work hours and CT deficits in operative experience both represent information highly valued by applicants. All had deficits in evaluation criteria and faculty mentorship. Detailed information on availability of specific content items can be seen in the Table. This study has uncovered key differences in availability of online content for residencies recruiting from the same pool of applicants. CT has the most information, then VS, with IR reporting the least content. To attract valuable candidates, programs should aim to increase the availability of online content for potential applicants.TableAvailability of content on US integrated interventional radiology (IR), integrated vascular surgery (VS), and integrated thoracic surgery training program websitesIR, No. (%) of programs (n = 74)VS, No. (%) of programs (n = 56)Thoracic surgery, No. (%) of programs (n = 27)Program recruitment Program description69 (93.2)56 (100.0)26 (96.3) Faculty listing73 (98.6)53 (94.6)27 (100.0) Faculty education (training history)68 (91.9)52 (92.9)25 (92.6) Admin/coordinator contact63 (85.1)53 (94.6)22 (81.5) Application requirements50 (67.6)42 (75.0)22 (81.5) ERAS link47 (63.5)35 (62.5)16 (59.3) Benefits51 (68.9)39 (69.6)19 (70.4) No. of incoming positions available45 (60.8)44 (78.6)20 (74.1) Salary48 (64.9)34 (60.7)17 (63.0) Current residents47 (63.5)40 (71.4)20 (74.1) Faculty publications40 (54.1)24 (42.9)19 (70.4) Wellbeing strategies37 (50.0)26 (46.4)17 (63.0) Interview dates29 (39.2)32 (57.1)13 (48.1) Alumni listing17 (23.0)20 (35.7)7 (25.9) Alumni career placement17 (23.0)15 (26.8)6 (22.2) Selection process13 (17.6)4 (7.1)2 (7.4) Debt management8 (10.8)22 (39.3)11 (40.7) Work hours6 (8.1)12 (21.4)12 (44.4)Program education Rotation schedule45 (60.8)47 (83.9)19 (70.4) Research interests (department)49 (66.2)22 (39.3)16 (59.3) Didactic instruction42 (56.8)39 (69.6)17 (63.0) Research requirements39 (52.7)41 (73.2)19 (70.4) Operative experience37 (50.0)18 (32.1)5 (18.5) Journal club25 (33.8)34 (60.7)11 (40.7) Meetings attended23 (31.1)26 (46.4)11 (40.7) Elective rotation20 (27.0)25 (44.6)12 (44.4) Curriculum12 (16.2)21 (37.5)10 (37.0) National organization link8 (10.8)4 (7.1)7 (25.9) Evaluation criteria5 (6.8)9 (16.1)6 (22.2) Simulation training3 (4.1)19 (33.9)9 (33.3)ERAS, Electronic Residency Application Service. Open table in a new tab

Critical Comparison of the Quality and Content of Integrated Vascular Surgery, Thoracic Surgery, and Interventional Radiology Residency Training Program Websites

Objective: With the move to virtual interviewing, residency websites are an important recruitment resource, introducing applicants to programs across the country and allowing for comparison. Recruitment is highly competitive from a common potential pool between vascular surgery, thoracic surgery and interventional radiology with the ratio of applicants to positions being highest in interventional radiology, followed by thoracic surgery and lastly vascular surgery, as reported by the National Resident Matching Program. The aim of this study is to evaluate the accessibility and availability of online content for those integrated residency programs. Methods: A list of accredited vascular surgery, thoracic surgery, and interventional radiology residencies was obtained from the ACGME. Program websites were evaluated by trained independent reviewers (n=2) for content items pertaining to program recruitment and education (scored absent or present). Statistical analysis was performed in R software. Results: Of ACGME accredited programs, 56 of 61 (92%) vascular surgery, 27 of 27 (100%) thoracic surgery, and 74 of 85 (87%) interventional radiology programs had functional websites (P=0.122). Vascular surgery websites contained a median of 26 content items (IQR: 20, 32), thoracic surgery websites contained a median of 27 content items (IQR: 21, 32), and interventional radiology websites contained a median of 23 content items (IQR: 18, 27). Two content items considered highly influential to applicant program decision are procedural experience and faculty mentorship, were reported at 32% and 11% for vascular surgery, 19% and 11% for thoracic surgery, and 50% and 15% for interventional radiology (P=0.008 and P=0.751, respectively). Key deficits were work hours, debt management and curriculum for interventional radiology; resident profiles, sample contracts, and research interests in vascular surgery; operative experiences, program director contact and message for thoracic surgery. Interventional radiology deficits were work hours and thoracic surgery deficits were procedural experience. Both IR and CT websites lacked information in evaluation criteria and faculty mentorship. Conclusions: This study has uncovered key differences in availability of online content for residencies recruiting from the same pool of applicants. Thoracic surgery has the most information, followed by vascular surgery, with interventional radiology reporting the least content. In the era of virtual interviewing from the same potential pool of applicants, programs should review and revise their web presence with the aim to increase the availability of online content in order to attract valuable candidates.

Incorporating single port video-assisted thoracic surgery training into regular thoracic surgery training programs

Between 2006 to 2011, I was the sole dedicated consultant thoracic surgeon serving 3 hospitals in Singapore with a combined total of >2,500 beds, and a catchment population of >2 million people.

Quality of Operative Performance Feedback Given to Thoracic Surgery Residents Using an App-Based System

Residents frequently report inadequate feedback both in quantity and quality. The study evaluates the quality of faculty feedback about operative performance given using an app-based system. Residents requested operative performance evaluation from faculty on a real-time basis using the "Zwisch Me!!" mobile application which allows faculty to provide brief written feedback. Qualitative analysis of feedback was performed using grounded theory. The 7 academic medical centers with thoracic surgery training programs. Volunteer thoracic surgery residents in both integrated and traditional training pathways and their affiliated cardiothoracic faculty. Residents (n = 33) at 7 institutions submitted a total of 596 evaluations to faculty (n = 48). Faculty acknowledged the evaluation request in 476 cases (80%) and in 350 cases (74%) provided written feedback. Initial open coding generated 12 categories of feedback type. We identified 3 overarching themes. The first theme was the tone of the feedback. Encouraging elements were identified in 162 comments (46%) and corrective elements in 230 (65%). The second theme was the topic of the feedback. Surgical technique was the most common category at 148 comments (42.2%) followed by preparation for case (n = 69, 19.7%). The final theme was the specificity of the feedback. Just over half of comments (n = 190, 54.3%) contained specific feedback, which could be applied to future cases. However, 51 comments (14.6%) contained no useful information for the learners. An app-based system resulted in thoracic surgery residents receiving identifiable feedback in a high proportion of cases. In over half of comments the feedback was specific enough to allow improvement. Feedback was better quality when addressing error prevention and surgical technique but was less useful when addressing communication, flow of the case, and assisting. Faculty development around feedback should focus on making feedback specific and actionable, avoiding case descriptions, or simple platitudes.

The Effect of Gender on Resident Autonomy in the Operating room

Discrimination against women training in medicine and surgery has been subjectively described for decades. This study objectively documents gender differences in the degree of autonomy given to thoracic surgery trainees in the operating room. Thoracic surgery residents and faculty underwent frame of reference training on the use of the 4-point Zwisch scale to measure operative autonomy. Residents and faculty then submitted evaluations of their perception of autonomy granted for individual operations as well as operative difficulty on a real-time basis using the "Zwisch Me!!" mobile application. Differences in autonomy given to male and female residents were elucidated using chi-square analysis and ordered logistic regression. Seven academic medical centers with thoracic surgery training programs. Volunteer thoracic surgery residents in both integrated and traditional training pathways and their affiliated cardiothoracic faculty. Residents (n = 33, female 18%) submitted a total of 596 evaluations to faculty (n = 48, female 12%). Faculty gave less autonomy to female residents with only 56 of 184 evaluations (30.3%) showing meaningful autonomy (passive help or supervision only) compared to 107 of 292 evaluations (36.7%) at those levels for male residents (p = 0.02). Resident perceptions of autonomy showed even more pronounced differences with female residents receiving only 38 of 197 evaluations (19.3%) with meaningful autonomy compared to 133 of 399 evaluations (33.3%) for male residents (p < 0.001). Potential influencing factors explored included attending gender and specialty, case type and difficulty, and resident level of training. In multivariate analysis, only case difficultly, resident gender, and level of training were significantly related to autonomy granted to residents. Evaluations of operative autonomy reveal a significant bias against female residents. Faculty education is needed to encourage allowing female residents more operative autonomy.

Online Learning in Thoracic Surgical Training: Promising Results of Multi-Institutional Pilot Study

Cardiothoracic surgical education faces numerous challenges, including reduced duty hours and diminishing prioritization of teaching, in the setting of rapidly advancing knowledge, skills, and case complexity. Pass rates on the American Board of Thoracic Surgery exam remain suboptimal, and new training formats are being evaluated. We hypothesize that Internet-based courses can be developed and implemented to supplement learning of basic topics in cardiothoracic surgery. After a needs assessment, 4 online self-study courses were developed by content experts using a Moodle [modular object-oriented dynamic learning environment] platform. As a pilot cohort, students from 4 thoracic surgery training programs participated, accessing courses at their own pace. Each course included general and detailed readings, multimedia content, discussion forum, and a question-bank supported quiz (90% required to pass, multiple attempts allowed). Utilization and exam data were tracked electronically. The t tests were used to compare first versus final-year traditional track trainees. Post-course surveys collected data on trainee attitudes. Nineteen students completed 4 courses on tracheal disease. Mean time spent per course and quiz attempts to pass were 1.35 hours and 2.86, respectively. Scores improved with successive attempts. Senior trainees showed a trend toward less time per course and fewer quiz attempts. Post-course surveys uniformly demonstrated perceived benefits from the content and quizzes in an easy-to-navigate format. Online courses can be developed and integrated within cardiothoracic training programs. This pilot demonstrates evidence of active learning as shown through the embedded assessments. Internet-based courses may serve as a means of supplementing modern thoracic surgical training. Further development and evaluation are warranted.

Genesis and Early Growth of The Society of Thoracic Surgeons

Fig 1. R. Adams Cowley, MD. Ftration among several surgeon groups desirous of starting a new professional society dedicated to thoracic surgery. At that time, certification in thoracic surgery was achieved only by way of an American Board of Surgery subspecialty section. Thoracic surgery training programs were variable in length and quality, and the only professional society concerned with the specialty was the American Association for Thoracic Surgery (AATS), which had a limitation on the number of active members (300), most of whom performed thoracic surgery as part of their general surgery practice. Dissatisfied surgeons wanted an organization for those interested in thoracic surgery to “call their own”; an organization that offered pride of membership and a forum for education and discussion of common interest subjects in the dynamic and rapidly changing field. A major impetus for this movement was championed by several members of the John Alexander Society, which was composed of surgeons who had trained at the University of Michigan under the tutelage of Dr Alexander, recognized by many as the “Founder of American Thoracic Surgery.” John Alexander Society meeting minutes are replete with references to discussions about the growing need and practicality of a new society. Of particular note is a meeting in Houston on April 8, 1963, when the formation of a “Committee on the Future of the John Alexander Society” was recorded. Although the surgeons involved in these formative activities were numerous, two were notably active at this stage, R. Adams Cowley, MD, of Baltimore (Fig 1) and Francis X. Byron, MD, of Duarte, California (Fig 2). Dr Cowley played a dominant role in discussions that led to the beginning of The Society of Thoracic Surgeons (STS). These discussions culminated in a recommendation that “a new society of thoracic and cardiovascular surgery be formed with the following objectives:

Teaching video-assisted thoracic surgery (VATS) lobectomy.

Video-assisted thoracic surgery (VATS) lobectomy has become the standard of care for early stage lung cancer throughout the world. Teaching this complex procedure requires adequate case volume, adequate instrumentation, a committed operating room team and baseline experience with open lobectomy. We outline what key maneuvers and steps are required to teach and learn VATS lobectomy. This is most easily performed as part of a thoracic surgery training program, but with adequate commitment and proctoring, there is no reason experienced open surgeons cannot become proficient VATS surgeons. We provide videos showing the key portions of a subcarinal lymph node dissection, posterior hilar dissection of the right upper lobe, fissureless right middle lobectomy, and fissureless left lower lobectomy. These videos highlight what we feel are important principals in VATS lobectomy, i.e., N2 and N1 lymph node dissection, fissureless techniques, and progressive responsibility of the learner. Current literature in simulation of VATS lobectomy is also outlined as this will be the future of teaching in VATS lobectomy.

A personal experience of 2-year general thoracic surgery training programs in Japan and the United States

The objective of the study is to review and compare two countries' thoracic surgery training programs. Retrospective review of the first author's prospectively maintained operative case logs in two countries was performed. Each training program was established in a teaching hospital for its country's board requirement. Preoperative diagnosis, operative procedures and postoperative diagnosis were reviewed. The case volume (overall and in each category) was also reviewed. The ratio of each category and overall case volume was compared between the two programs by Chi-square test. p value was considered significant if it is <0.05. The overall case volumes were 169 cases in the Japanese institution and 456 cases in the United States' institution. The number ratio of each category's procedures and overall procedures was as follows: pleural cases, Japan 19.2% versus the Unites States 20.6% (p=0.782), pulmonary cases, Japan 72.7% versus the United States 36.8% (p<0.0001), mediastinal cases, Japan 8.1% versus the United States 8.6% (p=0.678), diaphragm cases, Japan 0.62% versus the United States 13.2% (p=0.0001), chest wall cases, Japan 1.2% versus the United States 3.5% (p=0.0858), tracheobronchial cases, Japan 1.2% versus the United States 1.8% (p=0.583). Regarding the approach, the ratios of each approach and overall cases are as follows: minimally invasive approach, Japan 78.3% versus the United States 45.8% (p<0.0001), reoperative cases, Japan 0.62% versus the United States 3.1% (p=0.0411). Case variety is different between the two countries. Our findings suggest that thoracic surgery training in the United States may be beneficial for Japanese medical graduates.

Impact of a Six-Year Integrated Thoracic Surgery Training Program at the Medical College of Wisconsin

Thoracic residency program enrollment continues to decline. While job market and decreasing reimbursements are often cited as the main reasons, length of and format of training may also be significant. The Medical College of Wisconsin established an Accreditation Council for Graduate Medical Education-approved 6-year integrated thoracic training program. The number and characteristics of applicants to the 6-year program were then compared with previous applicants applying to the traditional 2-year program. Applicants to the 6-year integrated program scored higher on the United States Medical Licensing Examination part 1 and part 2 than previous applicants to the traditional 2-year program. The 6-year applicants also were more published and a greater percentage of them held other advanced degrees. Institution of a 6-year integrated thoracic surgery training program at the Medical College of Wisconsin led to a significant increase in number of applications. Additionally, the 6-year applicants appeared to be more academically accomplished than previous applicants to the traditional 2-year program. While early in the experience, it appears that interest in thoracic surgery is high among medical students and institution of a 6-year program has the potential to once again attract the "best and the brightest" to this specialty.

Thoracic Surgery Training in Canada According to the Residents: The Thoracic Surgery Resident Survey, of the Canadian Thoracic Manpower and Education Study (T-Med)

The resident component of the Canadian Thoracic Manpower and Education Study (T-MED) was conducted to understand the basic demographic of Canadian thoracic surgery residents, the factors influencing their selection of training programs, current work conditions, training and competencies, and opinions in regard to the manpower needs for the specialty. A modified Delphi process was used to develop a survey applicable to thoracic surgery residents. In May and June 2009, residents completed the voluntary anonymous Internet-based survey. All Canadian residents participated in the survey, providing a 100% response rate. Most respondents were male (11/12), and the average age was 34 years old with an anticipated debt greater than $50,000 on graduation. All residents worked more than 70 hours per week, with most doing 1 : 3 or 1 : 4 on-call. Two-thirds of respondents reported being satisfied or very satisfied with their training program. Rates of anticipated competence in performing various thoracic surgeries on graduation differed between residents and program directors. Two-thirds (8/12) of residents planned to practice thoracic surgery exclusively, and hoped to practice in an academic setting. Most residents (10/12) agreed or strongly agreed that not enough jobs are available in Canada for graduating trainees and that the number of residency positions should reflect the predicted availability of jobs. This study has provided detailed information on thoracic surgery resident demographics and training programs. Most thoracic surgery residents are satisfied with their current training program but have concerns about their job prospects on graduation, and they believe that the number of training positions should reflect potential job opportunities. This survey represents the first attempt to characterize the current state of thoracic surgery training in Canada from the resident's perspective and may help in directing educational and manpower planning.

Weathering the storm: How can thoracic surgery training programs meet the new challenges in the era of less-invasive technologies?

The introduction of new technologies has shifted some resident index procedures to nonsurgical specialists. We examined the operative case volume of thoracic surgery residents during the last 6 years to objectively identify changes and trends. Program and resident data from 2002 to 2007 were entered into a database and analyzed. Program match information was obtained from the National Resident Matching Program. Resident operative experience and board examination results were obtained from the American Board of Thoracic Surgery. A total of 795 residents qualified for the written American Board of Thoracic Surgery examination; 627 residents graduated from 2-year programs, and 168 residents graduated from 3-year programs. The total number of resident cases was higher in 3-year programs compared with 2-year programs in all 10 index categories studied (P < .01). The total volume of cases has not significantly increased in 2-year programs. The volume of coronary artery bypass graft surgeries decreased in every resident program model studied. The volume of general thoracic cases increased in all program models. Two-year, 2-resident programs had the lowest volume in 5 of the 10 categories, reaching significance in 3 categories. The written board pass rate was lower among 2-year programs than among 3-year programs (86% vs 95%, respectively, P = .003). Training programs have so far weathered the storm by maintaining index volume with a new case mix, but significant trends in revascularization procedures are concerning. This study indicates a significant advantage in case volume and board pass rates among 3-year programs. Thoracic residency programs should be reorganized so that the number of residents does not exceed the capacity of the program to provide a meaningful experience.

Thoracoscopic lobectomy: Introduction of a new technique into a thoracic surgery training program

Thoracoscopic lobectomy has been demonstrated to be safe and oncologically sound. However, few thoracic surgeons perform the operation. We hypothesized that use of a predetermined, stepwise plan for introduction of thoracoscopic lobectomy into a thoracic surgical training program would facilitate safe learning of the technique. Databases from 2 affiliated institutions were queried to identify all lobectomies during a 4-year period. Our model for introduction of thoracoscopic lobectomy was established expertise in open lobectomy and video-assisted thoracoscopic surgery, participation in a formal thoracoscopic lobectomy course, stepwise introduction of specific techniques used in thoracoscopic lobectomy into the operative approach, proctoring of initial thoracoscopic lobectomies by partners, and teaching of the technique to other thoracic surgeons and residents. We performed 202 lobectomies: 97 open and 105 thoracoscopic. Mortality was 3.0%. The conversion rate from thoracoscopic to open thoracotomy was 13%. When divided into quartiles, the percentage of lobectomies performed thoracoscopically increased from 18% in the first quartile to 82% in the fourth quartile. With ongoing experience, the procedure was performed at higher frequency by new staff and trainees. Residents performed 0% of thoracoscopic lobectomies in the first quartile, increasing to 54% in the third quartile. In the fourth quartile residents and a new staff surgeon performed 76% of thoracoscopic lobectomies. A resident was the operating surgeon for 37 thoracoscopic lobectomies. Introduction of thoracoscopic lobectomy into an academic thoracic surgical practice can be achieved safely if a stepwise transition is invoked. Training of thoracic surgical residents and additional staff can thus be effectively accomplished.

Where Have All the Cardiothoracic Surgery Residents Gone? Placement of Graduating Residents by United States Thoracic Surgery Training Programs, 1998 to 2002

We studied the evolving job placement trends of graduating cardiothoracic surgery residents over a 5-year period from the perspective of the program director. Graduate placement questionnaires were sent to program directors of Accreditation Council for Graduate Medical Education-accredited United States thoracic surgery residency programs (n = 92). Program directors were asked to categorize the type of job that each resident chose upon graduation (1998-2002). Of the program directors surveyed, 71.7% (66/92) responded, representing 76.4% (545/714) of the total graduating resident population during the study period. Three-year training programs constituted 24.2% (16/66) of the respondents and accounted for 20.2% (110/545) of the graduates. Annually, graduates most commonly chose private practice jobs. Between 2001 and 2002, the percentage of graduates entering fellowships increased (11.8% [13/110] versus 19.1% [21/110], P = .008) as the percentage of graduates choosing private practice positions decreased (56.4% [62/110] versus 45.5% [50/110], P = .15). In total, 12.8% (70/545) of the graduates pursued fellowships, with associated specialty choices being: 38.6% (27/70) adult cardiac, 37.1% (26/70) congenital, 15.7% (11/70) transplantation, and 8.6% (6/70) thoracic. There were no significant differences between 2-year and 3-year training program graduates in choice of private practice versus academic jobs. In 2002, a greater percentage of graduates chose to pursue fellowship training at the expense of private practice employment. This difference may in part result from fewer employment opportunities rather than graduate choice. Ongoing studies are needed to follow this trend. Annual analysis of the placement of all graduating residents would help to identify changes in employment.