- Email: [email protected]
A Decade of Change: Training and Career Paths of Cardiothoracic Surgery Residents 2003 to 2014
A Decade of Change: Training and Career Paths of Cardiothoracic Surgery Residents 2003 to 2014
Department of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, New York; Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia; Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia; Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington; Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Division of General Thoracic Surgery, Baylor College of Medicine, Houston, Texas; Pinnacle Health CardioVascular Institute, Harrisburg, Pennsylvania; Department of Surgery, Duke University, Durham, North Carolina; Division of Cardiac Surgery, Northwestern University, Chicago, Illinois; Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Division of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, New York; Department of Surgery, Congenital Heart Surgery, Texas Children’s Hospital, Houston, Texas; Department of Cardiothoracic Surgery, University of Iowa, Iowa City, Iowa; Division of Cardiothoracic Surgery, University of Mississippi, Oxford, Mississippi; Department of Cardiothoracic and Vascular Surgery, University of Texas Memorial Hermann-Texas Medical Center, Houston, Texas
Background. During the past decade, cardiothoracic surgery (CTS) education has undergone tremendous change with the advent of new technologies and the implementation of integrated programs, to name a few. The goal of this study was to assess how residents’ career paths, training, and perceptions changed during this period. Methods. The 2006 to 2014 surveys accompanying the Thoracic Surgery Residents Association/Thoracic Surgery Directors’ Association in-training examination taken by CTS residents were analyzed, along with a 2003 survey of graduating CTS residents. Of 2,563 residents surveyed, 2,434 (95%) responded. Results. During the decade, fewer residents were interested in mixed adult cardiac/thoracic practice (20% in 2014 vs 52% in 2003, p [ 0.004), more planned on additional training (10% in 2003 vs 41% to 47% from 2011 to 2014), and the frequent use of simulation increased from 1% in 2009 to 24% in 2012 (p < 0.001). More residents
recommended CTS to potential trainees (79% in 2014 vs 65% in 2010, p [ 0.007). Job offers increased from a low of 12% in 2008 with three or more offers to 34% in 2014. Debt increased from 0% with more than $200,000 in 2003 to 40% in 2013 (p < 0.001). Compared with residents in traditional programs, more integrated residents in 2014 were interested in adult cardiac surgery (53% vs 31%) and congenital surgery (22% vs 7%), fewer were interested in general thoracic surgery (5% vs 31%, p < 0.001), and more planned on additional training (66% vs 36%, p < 0.001). Conclusions. With the evolution in CTS over the last decade, residents’ training and career paths have changed substantially, with increased specialization and simulation accompanied by increased resident satisfaction and an improved job market.
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with implementation of nation-wide curricula, online resources, and simulation [1]. The implementation of workhour restrictions has demanded optimization of how the next generation of CTS residents is taught, with many programs supplementing their training with simulation. One of the most dramatic changes in CTS education has been the increasing adoption of the integrated cardiothoracic training paradigm. Although these changes have been well documented, how these changes have affected residents’ career paths and perceptions of the specialty and their training during this period have not been assessed. Following the pioneering work of Lee and colleagues [2] and the Thoracic
ardiothoracic surgery (CTS) has evolved substantially during the last decade with the advent of transcatheter valves, expanding use and repertoire of mechanical assist devices, as well as minimally invasive and robotic techniques. Accompanying our specialty’s transformation have been advances in CTS education
Accepted for publication April 1, 2015. Presented at the Fifty-first Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 24–28, 2015. Address correspondence to Dr Nguyen, 6400 Fannin St, Ste 2850, Houston, TX 77030; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;100:1305–14) Ó 2015 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.04.026
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Elizabeth H. Stephens, MD, PhD, David Odell, MD, William Stein, MD, Damien J. LaPar, MD, MS, Walter F. DeNino, MD, Muhammad Aftab, MD, Kathleen Berfield, MD, Amanda L. Eilers, DO, Shawn Groth, MD, John F. Lazar, MD, Michael P. Robich, MD, MPH, Asad A. Shah, MD, Danielle A. Smith, MD, Cameron Stock, MD, Vakhtang Tchantchaleishvili, MD, Carlos M. Mery, MD, MPH, Joseph W. Turek, MD, PhD, Jorge Salazar, MD, and Tom C. Nguyen, MD
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Surgery Residents Association (TSRA) in polling CTS residents’ perceptions and career paths in 2002, TSRA surveys now accompany the yearly in-training examination (ITE) taken by CTS residents. Using these surveys to evaluate residents’ perceptions and career paths may allow further refinement of how to best educate the next generation of cardiothoracic surgeons. To this end we used surveys of CTS residents from 2003 to 2014 to focus on three key areas during the last decade: (1) resident perception of training and the specialty, (2) career pathways, and (3) job market.
Material and Methods The 2006 to 2014 surveys accompanying the ITE taken by current CTS residents were analyzed along with a 2003 survey sent to graduating CTS residents. From 2007 to 2014 the survey was mandatory, whereas in 2006 and 2003 the survey was optional. There were no surveys accompanying the ITE in 2003 to 2005. Residents in nonaccredited fellowships were excluded. Changes over the years were compared with c2 testing and with post hoc testing. Subgroup analyses of the 2014 data assessed for potentially distinct populations within the residents in specialty interests and career paths. Comparisons were made between integrated and traditional residents (residents in 4þ3 programs were excluded from those analyses) and those interested in academic vs private practice. Logistic regression analysis was used to assess for an association between postgraduate year and additional training. Only the mean response rate was available for 2006 to 2009, thus preventing statistical comparison between these and the remaining years. SPSS 22.0 software (IBM Corp, Armonk, NY) was used for analysis. A p value of 0.05 or less was considered statistically significant.
Results Response Rate The response rate was 100% for 2007 to 2014, 54% in 2006, and 64% in 2003, for an overall response rate of 95% (2,434 of 2,563). Fig 1. Percentage of residents in integrated programs.
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Career Pathways: Program Types, Specialty Interests, and Additional Training As expected, given the advent of integrated programs, from 2003 to 2014 the percentage of residents in integrated programs increased from 0% in 2003 to 28% in 2014 (Fig 1). Specialty interests have changed over time, with decreasing interest in mixed cardiac/thoracic surgery (47% in 2003 vs 16% in 2014, p ¼ 0.004; Table 1, Fig 2) and a corresponding tendency to focus on adult cardiac surgery (33% in 2003 vs 39% in 2014) or thoracic surgery (15% in 2003 vs 23% in 2014). These changes in specialty interest were also statistically significant when graduating residents were examined. In recent years, more residents planned on pursuing additional training (40% to 47% in 2010 to 2014 vs 10% in 2003), most commonly in congenital heart surgery (24% to 31% in 2010 to 2014, Table 1). Logistic regression analysis did not show an association between postgraduate year and intention to pursue additional training. In 2013 there was the opportunity to select the reason for additional training. The most common reason for additional training was to allow for a specialized/niche practice (45% of residents), 21% cited additional training was for attaining additional skills not taught in their program, 7% to be competitive for the job they want, 4% because they did not feel adequately trained, 1% because they could not find a job, and 3% for other reasons. Over the course of the years, there has not been a significant change in academic vs private practice careers.
Perception of Adequacy of Training and Preparation for Boards In 2014, 89% of respondents (Fig 3) felt they were adequately trained after residency, which was increased from 79% in 2009 but was decreased from 97% in 2003. In 2003, 89% of respondents felt adequately prepared for the boards in 2003, but this decreased to 76% in 2013 and to 80% in 2014 (p < 0.05).
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Table 1. Specialty and Additional Traininga
Variable
2010 (n ¼ 299) No. (%)
2011 (n ¼ 305) No. (%)
2012 (n ¼ 313) No. (%)
2013 (n ¼ 317) No. (%)
2014 (n ¼ 317) No. (%)
29 42 13 5
(33) (47)A (15) (6) NA NA NA
93 69 66 30 14 15 5
108 60 61 31 18 10 3
108 62 72 30 23 3 4
127 52 77 32 12 7 7
121 51 72 42 11 15 1
NA NA NA
9 (8) 34 (30) NA
17 (14) 30 (24) NA
12 (10) 33 (26) NA
20 (14) 40 (27) 15 (10)
22 (16) 43 (31) 13 (9)
NA NA NA NA
12 13 21 26
24 17 15 23
19 20 12 29
18 17 13 25
15 13 14 19
p Value <0.001
(32) (24)B (23) (10) (5) (5)A (2)
(37) (21)B (21) (11) (6) (3) (1)
(36) (21)B (24) (10) (8) (1)B (1)
(40) (17)B (25) (10) (4) (2) (2)
(39) (16)B (23) (13) (4) (5) (0.3) <0.001
(10) (11) (18) (23)
(19) (14) (12) (18)
(15) (10) (10) (23)
(12) (12) (9) (17)
(11) (9) (10) (14)
a
Groups with different letters indicate statistically significant differences on post hoc testing, whereas groups with the same letters or no letters indicate b groups that were not significantly different. Only graduating residents were surveyed.
NA ¼ questions were not asked on that year’s survey.
Graduating Resident Debt Among graduating residents seeking jobs, the number of residents with no interviews decreased from 22% in 2006 to 3% in 2013. Correspondingly, those with three or more interviews increased from 34% in 2007 to 61% in 2013 and 2014. Those with three or more offers also increased from 12% in 2008 to 34% in 2014 (Fig 4).
Graduating resident debt increased substantially from 17% in 2003 with debt exceeding $150,000 to 43% in 2014 with debt exceeding $200,000 (Fig 5).
Career Satisfaction Residents appeared more satisfied with their career, with 79% recommending CTS to trainees in 2012 (not polled in
Fig 2. Specialty interest and intention to pursue additional training. For a given variable, data points with different letters were statistically significantly different on post hoc testing, whereas data points with the same letter or no letters were not statistically significantly different. Residents were queried regarding specialty interest (blue line ¼ mixed cardiac; red line ¼ adult cardiac; green line ¼ general thoracic; purple line ¼ congenital) and additional training (black dashed line) in separate questions, but their responses are plotted on the same graph for consolidation.
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Specialty interest Adult cardiac Mixed cardiac General thoracic Congenital Heart failure Aortic Other Additional training interest Aortic Congenital Endovascular Minimally invasive Cardiac Thoracic Other Transplant
2003 (n ¼ 89)b No. (%)
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Fig 3. Adequacy of training with oral board pass rates (green line) superimposed. Note: the board pass rate would reflect residents who graduated 1 to 2 years prior. (Blue line, adequately trained; red line, prepared for boards.) The p value is the overall p value comparing all years.
2013 and 2014), which was increased from 59% in 2009 (Fig 6). Correspondingly, those who would not recommend CTS to trainees decreased from 33% in 2007 to 9% in 2012. The same changes were noted when only graduating residents were analyzed.
Training Changes: Use of Thoracic Surgery Directors’ Association/TSRA Study Resources and Simulation Residents used a variety of resources to study for the ITE, ranging from the TSRA Review of Cardiothoracic Surgery (TSRA, Chicago, IL) to Self Education Self Assessment in Thoracic Surgery to textbooks. Over the course of 2011 to 2014 use of the TSRA Review book increased from 4% to 28% (p < 0.05, Fig 7), use of the Thoracic Surgery Directors’ Association (TSDA) curriculum increased from 5% to 12% (p < 0.05), whereas the use of Self Education Self Assessment in Thoracic Surgery decreased from 48% to 27% (p < 0.05), and the use of textbooks decreased from 37% to 22% (p < 0.05). Over the course of 2010 to 2012,
frequent use of simulation increased from 1% in 2010 to 24% in 2012 (p < 0.05, Fig 8).
Comparison of Integrated and Traditional Track Residents in 2014 Integrated residents in 2014 were more likely to be interested in congenital heart surgery (22% vs 8%, p < 0.05; Table 2) and less likely to be interested in general thoracic surgery (5% vs 31%, p < 0.05). Integrated residents were more likely to pursue additional training (66% vs 36%, p < 0.05), including training in congenital heart surgery (22% vs 9%, p < 0.05) and minimally invasive cardiac surgery (13% vs 2%, p < 0.05). More were interested in academic practice (57% vs 44%, p < 0.05). More integrated residents strongly agreed that they would be adequately trained after residency (59% vs 45%, p < 0.05) and adequately prepared for the boards (42% vs 28%, p < 0.05).
Comparison of Residents Interested in Academic vs Private Practice in 2014 Those interested in academic practice had distinct specialty interests (Table 3), including a greater interest in congenital surgery (18% vs 2%, p < 0.05) and less interest in mixed cardiac and thoracic surgery (7% vs 37%, p < 0.05). Similarly, more residents interested in academic surgery were planning on doing additional training (51% vs 32%, p < 0.05), including additional training in congenital heart surgery (18% vs 2%, p < 0.05). There were no differences in debt, residents’ perception of adequacy of training, or preparation for the boards.
Comment
Fig 4. Percentage of job seekers with none (blue line), 1 or 2 (red line), or more than 2 (green line) firm job offers. The p value represents the overall p value comparing all years.
Over the course of the last decade, the field of CTS and CTS education has undergone dramatic changes. This study focused on residents’ career paths and perceptions of their training and the specialty in the context of these changes.
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Fig 5. Graduating residents with debt greater than $200,000. However in 2008 the cutoff was >$150,000 (not >$200,000). Data do not take into account inflation. ADULT CARDIAC
Career Pathways: Increased Specialization and Additional Training Over the years the number of residents entering mixed cardiac/thoracic practices has decreased, with more focusing on cardiac or thoracic surgery and more residents pursuing additional training. During this time the field has become increasingly specialized, requiring specific skill sets and knowledge bases; for example, an endovascular skill set is required in the case of transcatheter aortic valve replacement, and with the increasing array of ventricular assist devices, specific knowledge and experience with individual devices is necessary. Some may argue that the increase in additional training reflects a deficiency in training because graduates do not feel adequately prepared. However, this more likely reflects the complexity and increasing subspecialization of the field such that a base of knowledge is acquired during fellowship and specialized techniques are obtained during periods of additional
training [3]. Indeed, the 2013 data show that the vast majority of residents were pursuing additional training to have a specialty practice, to refine skills learned in their program, or to obtain skills not taught in their program, and only 4% were pursuing additional training because they felt inadequately trained.
Expanding Job Market Although in previous years (2007 to 2008, 2011) 35% to 40% had no job offers by March, that decreased to 20% in the last 3 years. Meanwhile, 30% to 34% had three or more offers compared with 12% in 2008, suggesting an improved job market. However, debt has increased substantially, with 43% graduating with debt exceeding $200,000; this increase in debt remains substantial despite the approximately 29% inflation over the span of the study. Increasing debt does not appear to be influencing residents’ choice of private careers over academic careers.
Perception of the Specialty
Fig 6. Percentage of residents who would recommend cardiothoracic surgery (CTS) to trainees. The p value represents the overall p value comparing all years. For a given variable, data points with different letters were statistically significantly different on post hoc testing, whereas data points with the same letter or no letters were not statistically significantly different. (Blue line, agree; red line, neutral; green line, disagree.)
Since 1994 the number of applicants to traditional CTS fellowships has steadily declined [4]. The reasons behind this decline and potential ways to increase interest in CTS have been extensively discussed [5]. Length of training, job security, lifestyle, and concerns regarding the future of the specialty have been considered contributing factors [4, 6, 7], as highlighted in the initial 2002 TSRA survey polling graduating CTS residents [2]. Potential trainees exposed to cardiothoracic surgeons and fellows satisfied by their career choice will help recruit more to the specialty. Our data show that residents are increasingly satisfied with their career choice: 79% in 2012 would recommend CTS to potential trainees in 2012 compared with 59% in 2009. As in other studies [8, 9], mentorship was key to career choice as well as personal experience and case variety. These results confirm the importance of exposure to the specialty, allowing residents to observe the case variety and find mentorship. For integrated programs, this exposure must occur in medical school or before, hence, the
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Fig 7. Study aids for the in training exam. (Blue line, Thoracic Surgery Residents’ Association (TSRA) Review; red line, Thoracic Surgery Directors’ Association (TSDA) curriculum; green line, Self Education Self Assessment in Thoracic Surgery (SESATS); turquoise line, textbooks; blue line, TSRA clinical scenarios.)
efforts by the Joint Council for Thoracic Surgery Education [6] and national societies to increase exposure of younger students to the field.
Perception of CTS Educational Resources: Increasing Use of TSDA/TSRA Resources and Simulation With the increasing interest in CTS education and efforts to optimize education in light of work-hour restrictions, the Joint Council for Thoracic Surgery Education and TSDA have invested heavily in providing programs with curricular resources. Most recently in August 2013 the thoracic “brain”/“Moodle” was launched, providing a comprehensive system with a wide variety of searchable resources, structured curriculum, and ability for the resident and program to both monitor resident progress. The TSRA has also
Fig 8. Percentage of residents who frequently (blue line), occasionally (red line), or rarely (green line) use simulation. The p value represents the overall p value comparing all years. For a given variable, data points with different letters were statistically significantly different on post hoc testing, whereas data points with the same letter or no letters were not statistically significantly different.
invested heavily in improving educational resources, including publishing the TSRA Review and TSRA Clinical Scenarios. Unfortunately, the survey in 2014 did not include a question querying the residents’ perception of the thoracic “brain”/“Moodle,” but the TSDA curriculum was increasingly used as a study aid for the ITE, as was the TSRA Review, while reliance on Self Education Self Assessment in Thoracic Surgery and textbooks (both online and paper) decreased. Therefore, the educational resources provided by the TSDA/Joint Council for Thoracic Surgery Education and TSRA appear to have found a substantial role in the training of residents. Given the work-hour restrictions and inherent limitations of learning operative techniques in the operating room, attention has turned to simulation as an
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Table 2. Comparison of 2014 Integrated and Traditional Residents
Variable
a
Traditional (n ¼ 200 [69%]) No. (%)
p Value <0.001
47 4 19 4 5 9 0
(53) (5) (22)a (5)a (6) (10) (0)
65 11 16 62 6 39 1
(33) (6) (8)a (31)a (3) (20) (1)
7 19 7 11 3 2 9 30
(8) (22)a (8) (13)a (3) (2) (10) (34)a
15 17 5 4 9 12 10 128
(8) (9)a (3) (2)a (5) (6) (5) (64)a
52 26 8 1 1
(59)a (30)a (9) (1) (1)
89 87 15 9 0
(45)a (44)a (8) (5) (0)
37 41 8 1 1
(42)a (47) (9)a (1) (1)
56 94 45 5 0
(28)a (47) (23)a (3) (0)
25 20 28 15
(28) (23) (32) (17)
77 43 45 35
(39) (22) (23) (17)
<0.001
0.038
0.014
0.27
0.049 50 (57)a 12 (14)a 26 (30)
88 (44)a 51 (26)a 61 (31)
Indicates groups that were significantly different on post hoc testing.
adjunct training tool [10]. The frequent use of simulation by residents has increased from 1% in 2010 to 24% in 2012.
Perceptions Regarding Adequacy of Training and Board Preparation Clearly, resident perception of adequacy of training and, in particular, board preparation is a complex issue. Numerous factors contribute to these perceptions, ranging from the highly publicized decreased board passing rate [11] to actual differences in the level of resident preparedness. A large portion of the onus for
board preparation rests on the resident, who must put in the time and effort to prepare. Preparedness is difficult to quantify, and the data in this study did not link perception to ITE scores, board passing rate, or actual technical competence. Despite these limitations, examining residents’ perceived preparedness is important. The present data indicate there appears to be an improvement in resident perception of adequacy of training over the last several years, although down from a high of 97% in 2003. Perception of preparedness for the boards remains below the level of 2011. Multiple efforts are underway to try to improve resident preparation, and how effective those are
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Interest Adult cardiac Aortic Congenital General thoracic Heart failure Mixed cardiac Other Additional training Aortic Congenital Endovascular Minimally invasive cardiac Minimally invasive thoracic Other Transplant None Adequately trained after residency Strongly agree Agree Neutral Disagree Strongly disagree Adequately prepared for boards Strongly agree Agree Neutral Disagree Strongly disagree Debt <$100,000 $100,000–$200,000 $200,000–$300,000 >$300,000 Practice type Academic Private Undecided
Integrated (n ¼ 88 [31%]) No. (%)
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Table 3. Comparison of Residents Interested in Academic Versus Private Practice From the 2014 Survey
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Variable Interest Adult cardiac Aortic Congenital General thoracic Heart failure Mixed cardiac Other Additional training Aortic Congenital Endovascular Minimally invasive cardiac Minimally invasive thoracic Other Transplant None Adequately trained after residency Strongly agree Agree Neutral Disagree Strongly disagree Adequately prepared for boards Strongly agree Agree Neutral Disagree Strongly disagree Debt <$100,000 $100,000–$200,000 $200,000–$300,000 >300,000 a
Academic (n ¼ 138 [48%]) No. (%)
Private (n ¼ 63 [22%]) No. (%)
Undecided (n ¼ 88 [31%]) No. (%)
P Value <0.001
48 8 25 38 9 10 0
(35) (6) (18)a (28) (7) (7)a (0)
26 3 1 10 0 23 0
(41) (5) (2)a (16) (0) (37)a (0)
38 4 9 18 2 15 1
(44) (5) (10) (21) (2) (17)a (1)
12 25 6 7 6 2 13 67
(9) (18)a (4) (5) (4) (1)a (9) (49)a
4 1 3 3 2 5 2 43
(6) (2)a (5) (5) (3) (8) (3) (68)a
6 10 3 5 4 7 4 48
(7) (12) (3) (6) (5) (8)a (5) (55)
75 53 8 2 0
(54) (38) (6) (1) (0)
31 24 4 4 0
(49) (38) (6) (6) (0)
35 36 11 4 1
(40) (41) (13) (5) (1)
55 62 18 3 0
(40) (45) (13) (2) (0)
16 30 15 2 0
(25) (48) (24) (3) (0)
22 43 20 1 1
(25) (49) (23) (1) (1)
59 29 33 17
(43) (21) (24) (12)
18 13 16 16
(29) (21) (24) (25)
25 21 24 17
(29) (24) (28) (20)
0.058
0.176
0.146
0.162
Indicates groups that were significantly different on post hoc testing.
in improving board pass rates and residents’ perception of their preparedness remains to be seen.
Distinct Populations: Integrated and Traditional Track Residents As anticipated since the advent of integrated 6-year programs, the percentage of respondents in such programs has increased substantially, totaling 28% in 2014. This reflects a paradigm shift, as increasingly cardiothoracic surgeons will be trained using this pathway. The optimization of this training pathway remains very much a work in progress because most programs have not yet graduated a class. Given the increasing proportion of integrated residents, analysis of the 2014 data assessed for differences between integrated and traditional track residents.
Prior studies from single institutions comparing applicants from both tracks reported higher United States Medical Licensing Examination scores and more advanced degrees in integrated applicants [12–14], variables not evaluated in this study. Not surprisingly, given the preponderance of integrated programs that focus on cardiac surgery, in 2014 integrated residents were less likely to be interested in general thoracic surgery and more likely to be interested in congenital heart surgery. In addition, more integrated residents planned on pursuing additional training and academic careers. This is consistent with previous surveys of integrated residents demonstrating a high interest in academic careers (91% to 95%) [9, 15] and plans on additional training (77%) [9, 16]. Given the large number of integrated residents who are still in their junior
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The authors wish to thank Beth Winer for assistance in obtaining data and previous TSRA executive committee members for their leadership in designing and implementing the TSRA ITE surveys.
References 1. Verrier ED. Joint Council on Thoracic Surgical Education: an investment in our future. J Thorac Cardiovasc Surg 2011;141: 318–21. 2. Lee R. Help wanted. Ann Thorac Surg 2003;76:1779–81.
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3. Nguyen TC, Terwelp MD, Stephens EH, et al. Resident perceptions of 2 vs. 3-year cardiothoracic training programs. Ann Thorac Surg 2015: http://dx.doi.org/10.1016/j. athoracsur.2015.01.031 [Epub ahead of print]. 4. Vaporciyan AA, Reed CE, Erikson C, et al. Factors affecting interest in cardiothoracic surgery: survey of North American general surgery residents. J Thorac Cardiovasc Surg 2009;137:1054–62. 5. Chitwood WR Jr, Spray TL, Feins RH, Mack MJ. Mission critical: thoracic surgery education reform. Ann Thorac Surg 2008;86:1061–2. 6. Kim AW, Reddy RM, Higgins RS, Joint Council for Thoracic Surgical Education Subcommittee B, Brightest. “Back to the future”: recruiting the best and brightest into cardiothoracic surgery. J Thorac Cardiovasc Surg 2010;140:503–4. 7. Vaporciyan AA, Yang SC, Baker CJ, Fann JI, Verrier ED. Cardiothoracic surgery residency training: past, present, and future. J Thorac Cardiovasc Surg 2013;146:759–67. 8. Vaporciyan AA, Reed CE, Erikson C, et al. Factors affecting interest in cardiothoracic surgery: survey of North American general surgery residents. Ann Thorac Surg 2009;87:1351–9. 9. Lebastchi AH, Yuh DD. Nationwide survey of us integrated 6-year cardiothoracic surgical residents. J Thorac Cardiovasc Surg 2014;148:401–7. 10. Carpenter AJ, Yang SC, Uhlig PN, Colson YL. Envisioning simulation in the future of thoracic surgical education. J Thorac Cardiovasc Surg 2008;135:477–84. 11. Moffatt-Bruce SD, Ross P, Williams TE Jr. American Board of Thoracic Surgery examination: fewer graduates, more failures. J Thorac Cardiovasc Surg 2014;147:1464–9. 12. Gasparri MG, Tisol WB, Masroor S. Impact of a six-year integrated thoracic surgery training program at the Medical College of Wisconsin. Ann Thorac Surg 2012;93:592–5; discussion 596–7. 13. Varghese TK Jr, Mokadam NA, Verrier ED, Wallyce D, Wood DE. Motivations and demographics of I-6 and traditional 5þ2 cardiothoracic surgery resident applicants: insights from an academic training program. Ann Thorac Surg 2014;98:877–83. 14. Chikwe J, Brewer Z, Goldstone AB, Adams DH. Integrated thoracic residency program applicants: the best and the brightest? Ann Thorac Surg 2011;92:1586–91. 15. Tchantchaleishvili V, Barrus B, Knight PA, Jones CE, Watson TJ, Hicks GL. Six-year integrated cardiothoracic surgery residency applicants: characteristics, expectations, and concerns. J Thorac Cardiovasc Surg 2013;146:753–8. 16. Tchantchaleishvili V, LaPar DJ, Stephens EH, Berfield KS, Odell DD, DeNino WF. Current integrated cardiothoracic surgery residents: a Thoracic Surgery Residents Association survey. Ann Thorac Surg 2015;99:1040–7.
DISCUSSION DR ROBERT S.D. HIGGINS (Columbus, OH): It was very exciting to see your presentation. It was well done, obviously. It is fantastic information that I think everybody in the specialty is interested in hearing. I am thinking about the correlation between the residents’ perception of their preparation for the board and how their preparation has changed in terms of the source of information and what they use to prepare for the exam. We understand that the exam has changed a bit over the last several years, but maybe you can help me understand a little bit more about that correlation. I think it is important. There are others in the audience who think about that correlation. They are all bright people. They all work hard. They are all accomplished. They ought to be able to prepare for the exam. I am trying to figure out where the problem is.
DR STEPHENS: Thank you for an excellent question. It brings up several important points, one of which is that we do not have an association between particular residents who did not feel well prepared and whether they in fact performed more poorly on the oral and/or written boards, and whether their poor performance was specifically on the written or oral boards. Dr Moffatt-Bruce studied both written and oral board pass rates, and over time the written board pass rates started to improve, while the oral board pass rates still struggled, although there was an up-trend. The oral and written boards are two distinct types of examinations in terms of the type of knowledge assessed: the written boards consist more of “book” knowledge, while the oral boards test clinical knowledge and judgment. In terms of specific resources that residents are using, we from the Thoracic Surgery Residents Association (TSRA) are hoping that the clinical
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years, whether these distinctions between the two populations are born out when the integrated residents graduate remain to be seen. The integrated training paradigm remains a work in progress, with ongoing changes in program structure and expectations, and only two graduated classes to date. Some have expressed concern about the adequacy of training in the integrated track, speculating that some residents may require additional training [9]. However, there is also a trend moving toward advanced training as the field becomes more specialized. This study has some limitations. The 2003 and 2006 surveys both had a significantly lower response rate, which could have biased the results. In addition, raw data for 2006 to 2009 were not available, precluding statistical comparison between those and remaining years, which also limits conclusions that can be made regarding change during the last decade. Changes in survey questions and response choices also limited the comparisons. Further, the mandatory nature of the questionnaire may cast doubt on the sincerity and comprehensiveness of residents’ responses. Given the same residents answer the survey every year of their training, the results may be unduly influenced by individual responses. Debt was not adjusted by inflation each year. In summary, with the changes occurring in CTS over the last decade, residents are more satisfied with their career choice and are enjoying increasing job opportunities, with more residents pursuing advanced training.
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scenarios would be helpful in preparation for the oral boards and the Thoracic Surgery Directors’ Association (TSDA) curriculum and TSRA review might be more helpful in terms of “book” knowledge tested in the written boards. These are excellent questions and the Board and the Residency Review Committee (RRC) take the oral and written board pass rates very seriously and are very involved in trying to help residents pass. DR HIGGINS: I would argue that that is an important area for all parties, TSDA, TSRA, and the Board, to think about the linkage between what materials and what curricular activities and what oral board preparation occurs and how that will affect the resident’s confidence in pursuing those milestones. It is really important. DR STEPHENS: Right, and we did not look at whether certain resources actually provided better preparation than other resources. DR PAUL H. SCHIPPER (Portland, OR): I am building an Integrated-6 (I-6) program, and one of the things I am trying to roll into that is the cardiac track and the thoracic track. You have these levels of interest for adult cardiac, congenital, general thoracic, heart failure. I am curious to know if you have data looking across the integrated tracks to see if those percentages change from the first year to the second year and third year. DR STEPHENS: That is something we have not looked at: stratifying by year; even talking to fellow residents as they move through, their interests change. I should also point out that this polling does not take into account their ultimate career choice. Someone coming in as an intern, as an I-6, might say they are interested in congenital heart surgery and then they get to be a postgraduate year 4 and they decide to do adult cardiac, or they might say they are interested in an academic career, but do they actually pursue an academic career? Do they get an academic job? That is something that we have not looked at. DR JOHN DAVID VEGA (Atlanta, GA): There is a large discrepancy between the number of applicants for I-6 positions and the actual positions available. Do we have any data yet on what those I-6 individuals do who do not get into an Integrated-6 program? Are they still interested in cardiothoracic surgery?
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Depending on the answer, that implies: Are you passionate about cardiothoracic, are you going to do it regardless of whether it takes you 6 years or 10 years, or are you just interested in it if you can do it in 6 years because it is sexy, etc? DR STEPHENS: That is an excellent point. I am not aware of any data. I do not know if Dr Vaporciyan is. DR ARA A. VAPORCIYAN (Houston, TX): You cannot get that data directly from the National Resident Matching Program (NRMP), but what the I-6 programs and the I-6 committee have done is they have asked the applicants if it would be okay if we could contact them later, and then they are trying to pull together resources. So each I-6 program is writing down everybody they interviewed and sending it centrally to Beth Winer, and then she is sort of trying to figure out the total applicant pool so that we can reach out to them. DR VEGA: They should know. I mean they are registering for a match, right? DR VAPORCIYAN: Correct. DR VEGA: So that data should be there in terms of individuals. You just have to track them. DR VAPORCIYAN: Yes, but we cannot access that from the NRMP. We cannot get that from them. DR HIGGINS: And the other thing, David, is that it could be 5 years later. DR VEGA: Yes, I understand they are several years down the road. I think it is important data to know. DR VAPORCIYAN: Absolutely, although I think we are seeing an uptake this year in applicants. I have not seen the numbers, but just gauging my discussions across this meeting, there are many more applicants for the traditional programs than there have been in the last few years, and the timing, considering that the I-6 programs have been around for about 7 years now, is about right for these people to be maturing through a general surgery path and maintaining that interest. I do not know.
Department of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, New York; Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia; Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia; Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington; Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Division of General Thoracic Surgery, Baylor College of Medicine, Houston, Texas; Pinnacle Health CardioVascular Institute, Harrisburg, Pennsylvania; Department of Surgery, Duke University, Durham, North Carolina; Division of Cardiac Surgery, Northwestern University, Chicago, Illinois; Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Division of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, New York; Department of Surgery, Congenital Heart Surgery, Texas Children’s Hospital, Houston, Texas; Department of Cardiothoracic Surgery, University of Iowa, Iowa City, Iowa; Division of Cardiothoracic Surgery, University of Mississippi, Oxford, Mississippi; Department of Cardiothoracic and Vascular Surgery, University of Texas Memorial Hermann-Texas Medical Center, Houston, Texas
Background. During the past decade, cardiothoracic surgery (CTS) education has undergone tremendous change with the advent of new technologies and the implementation of integrated programs, to name a few. The goal of this study was to assess how residents’ career paths, training, and perceptions changed during this period. Methods. The 2006 to 2014 surveys accompanying the Thoracic Surgery Residents Association/Thoracic Surgery Directors’ Association in-training examination taken by CTS residents were analyzed, along with a 2003 survey of graduating CTS residents. Of 2,563 residents surveyed, 2,434 (95%) responded. Results. During the decade, fewer residents were interested in mixed adult cardiac/thoracic practice (20% in 2014 vs 52% in 2003, p [ 0.004), more planned on additional training (10% in 2003 vs 41% to 47% from 2011 to 2014), and the frequent use of simulation increased from 1% in 2009 to 24% in 2012 (p < 0.001). More residents
recommended CTS to potential trainees (79% in 2014 vs 65% in 2010, p [ 0.007). Job offers increased from a low of 12% in 2008 with three or more offers to 34% in 2014. Debt increased from 0% with more than $200,000 in 2003 to 40% in 2013 (p < 0.001). Compared with residents in traditional programs, more integrated residents in 2014 were interested in adult cardiac surgery (53% vs 31%) and congenital surgery (22% vs 7%), fewer were interested in general thoracic surgery (5% vs 31%, p < 0.001), and more planned on additional training (66% vs 36%, p < 0.001). Conclusions. With the evolution in CTS over the last decade, residents’ training and career paths have changed substantially, with increased specialization and simulation accompanied by increased resident satisfaction and an improved job market.
C
with implementation of nation-wide curricula, online resources, and simulation [1]. The implementation of workhour restrictions has demanded optimization of how the next generation of CTS residents is taught, with many programs supplementing their training with simulation. One of the most dramatic changes in CTS education has been the increasing adoption of the integrated cardiothoracic training paradigm. Although these changes have been well documented, how these changes have affected residents’ career paths and perceptions of the specialty and their training during this period have not been assessed. Following the pioneering work of Lee and colleagues [2] and the Thoracic
ardiothoracic surgery (CTS) has evolved substantially during the last decade with the advent of transcatheter valves, expanding use and repertoire of mechanical assist devices, as well as minimally invasive and robotic techniques. Accompanying our specialty’s transformation have been advances in CTS education
Accepted for publication April 1, 2015. Presented at the Fifty-first Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 24–28, 2015. Address correspondence to Dr Nguyen, 6400 Fannin St, Ste 2850, Houston, TX 77030; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;100:1305–14) Ó 2015 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.04.026
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Elizabeth H. Stephens, MD, PhD, David Odell, MD, William Stein, MD, Damien J. LaPar, MD, MS, Walter F. DeNino, MD, Muhammad Aftab, MD, Kathleen Berfield, MD, Amanda L. Eilers, DO, Shawn Groth, MD, John F. Lazar, MD, Michael P. Robich, MD, MPH, Asad A. Shah, MD, Danielle A. Smith, MD, Cameron Stock, MD, Vakhtang Tchantchaleishvili, MD, Carlos M. Mery, MD, MPH, Joseph W. Turek, MD, PhD, Jorge Salazar, MD, and Tom C. Nguyen, MD
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Surgery Residents Association (TSRA) in polling CTS residents’ perceptions and career paths in 2002, TSRA surveys now accompany the yearly in-training examination (ITE) taken by CTS residents. Using these surveys to evaluate residents’ perceptions and career paths may allow further refinement of how to best educate the next generation of cardiothoracic surgeons. To this end we used surveys of CTS residents from 2003 to 2014 to focus on three key areas during the last decade: (1) resident perception of training and the specialty, (2) career pathways, and (3) job market.
Material and Methods The 2006 to 2014 surveys accompanying the ITE taken by current CTS residents were analyzed along with a 2003 survey sent to graduating CTS residents. From 2007 to 2014 the survey was mandatory, whereas in 2006 and 2003 the survey was optional. There were no surveys accompanying the ITE in 2003 to 2005. Residents in nonaccredited fellowships were excluded. Changes over the years were compared with c2 testing and with post hoc testing. Subgroup analyses of the 2014 data assessed for potentially distinct populations within the residents in specialty interests and career paths. Comparisons were made between integrated and traditional residents (residents in 4þ3 programs were excluded from those analyses) and those interested in academic vs private practice. Logistic regression analysis was used to assess for an association between postgraduate year and additional training. Only the mean response rate was available for 2006 to 2009, thus preventing statistical comparison between these and the remaining years. SPSS 22.0 software (IBM Corp, Armonk, NY) was used for analysis. A p value of 0.05 or less was considered statistically significant.
Results Response Rate The response rate was 100% for 2007 to 2014, 54% in 2006, and 64% in 2003, for an overall response rate of 95% (2,434 of 2,563). Fig 1. Percentage of residents in integrated programs.
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Career Pathways: Program Types, Specialty Interests, and Additional Training As expected, given the advent of integrated programs, from 2003 to 2014 the percentage of residents in integrated programs increased from 0% in 2003 to 28% in 2014 (Fig 1). Specialty interests have changed over time, with decreasing interest in mixed cardiac/thoracic surgery (47% in 2003 vs 16% in 2014, p ¼ 0.004; Table 1, Fig 2) and a corresponding tendency to focus on adult cardiac surgery (33% in 2003 vs 39% in 2014) or thoracic surgery (15% in 2003 vs 23% in 2014). These changes in specialty interest were also statistically significant when graduating residents were examined. In recent years, more residents planned on pursuing additional training (40% to 47% in 2010 to 2014 vs 10% in 2003), most commonly in congenital heart surgery (24% to 31% in 2010 to 2014, Table 1). Logistic regression analysis did not show an association between postgraduate year and intention to pursue additional training. In 2013 there was the opportunity to select the reason for additional training. The most common reason for additional training was to allow for a specialized/niche practice (45% of residents), 21% cited additional training was for attaining additional skills not taught in their program, 7% to be competitive for the job they want, 4% because they did not feel adequately trained, 1% because they could not find a job, and 3% for other reasons. Over the course of the years, there has not been a significant change in academic vs private practice careers.
Perception of Adequacy of Training and Preparation for Boards In 2014, 89% of respondents (Fig 3) felt they were adequately trained after residency, which was increased from 79% in 2009 but was decreased from 97% in 2003. In 2003, 89% of respondents felt adequately prepared for the boards in 2003, but this decreased to 76% in 2013 and to 80% in 2014 (p < 0.05).
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Table 1. Specialty and Additional Traininga
Variable
2010 (n ¼ 299) No. (%)
2011 (n ¼ 305) No. (%)
2012 (n ¼ 313) No. (%)
2013 (n ¼ 317) No. (%)
2014 (n ¼ 317) No. (%)
29 42 13 5
(33) (47)A (15) (6) NA NA NA
93 69 66 30 14 15 5
108 60 61 31 18 10 3
108 62 72 30 23 3 4
127 52 77 32 12 7 7
121 51 72 42 11 15 1
NA NA NA
9 (8) 34 (30) NA
17 (14) 30 (24) NA
12 (10) 33 (26) NA
20 (14) 40 (27) 15 (10)
22 (16) 43 (31) 13 (9)
NA NA NA NA
12 13 21 26
24 17 15 23
19 20 12 29
18 17 13 25
15 13 14 19
p Value <0.001
(32) (24)B (23) (10) (5) (5)A (2)
(37) (21)B (21) (11) (6) (3) (1)
(36) (21)B (24) (10) (8) (1)B (1)
(40) (17)B (25) (10) (4) (2) (2)
(39) (16)B (23) (13) (4) (5) (0.3) <0.001
(10) (11) (18) (23)
(19) (14) (12) (18)
(15) (10) (10) (23)
(12) (12) (9) (17)
(11) (9) (10) (14)
a
Groups with different letters indicate statistically significant differences on post hoc testing, whereas groups with the same letters or no letters indicate b groups that were not significantly different. Only graduating residents were surveyed.
NA ¼ questions were not asked on that year’s survey.
Graduating Resident Debt Among graduating residents seeking jobs, the number of residents with no interviews decreased from 22% in 2006 to 3% in 2013. Correspondingly, those with three or more interviews increased from 34% in 2007 to 61% in 2013 and 2014. Those with three or more offers also increased from 12% in 2008 to 34% in 2014 (Fig 4).
Graduating resident debt increased substantially from 17% in 2003 with debt exceeding $150,000 to 43% in 2014 with debt exceeding $200,000 (Fig 5).
Career Satisfaction Residents appeared more satisfied with their career, with 79% recommending CTS to trainees in 2012 (not polled in
Fig 2. Specialty interest and intention to pursue additional training. For a given variable, data points with different letters were statistically significantly different on post hoc testing, whereas data points with the same letter or no letters were not statistically significantly different. Residents were queried regarding specialty interest (blue line ¼ mixed cardiac; red line ¼ adult cardiac; green line ¼ general thoracic; purple line ¼ congenital) and additional training (black dashed line) in separate questions, but their responses are plotted on the same graph for consolidation.
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Specialty interest Adult cardiac Mixed cardiac General thoracic Congenital Heart failure Aortic Other Additional training interest Aortic Congenital Endovascular Minimally invasive Cardiac Thoracic Other Transplant
2003 (n ¼ 89)b No. (%)
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Fig 3. Adequacy of training with oral board pass rates (green line) superimposed. Note: the board pass rate would reflect residents who graduated 1 to 2 years prior. (Blue line, adequately trained; red line, prepared for boards.) The p value is the overall p value comparing all years.
2013 and 2014), which was increased from 59% in 2009 (Fig 6). Correspondingly, those who would not recommend CTS to trainees decreased from 33% in 2007 to 9% in 2012. The same changes were noted when only graduating residents were analyzed.
Training Changes: Use of Thoracic Surgery Directors’ Association/TSRA Study Resources and Simulation Residents used a variety of resources to study for the ITE, ranging from the TSRA Review of Cardiothoracic Surgery (TSRA, Chicago, IL) to Self Education Self Assessment in Thoracic Surgery to textbooks. Over the course of 2011 to 2014 use of the TSRA Review book increased from 4% to 28% (p < 0.05, Fig 7), use of the Thoracic Surgery Directors’ Association (TSDA) curriculum increased from 5% to 12% (p < 0.05), whereas the use of Self Education Self Assessment in Thoracic Surgery decreased from 48% to 27% (p < 0.05), and the use of textbooks decreased from 37% to 22% (p < 0.05). Over the course of 2010 to 2012,
frequent use of simulation increased from 1% in 2010 to 24% in 2012 (p < 0.05, Fig 8).
Comparison of Integrated and Traditional Track Residents in 2014 Integrated residents in 2014 were more likely to be interested in congenital heart surgery (22% vs 8%, p < 0.05; Table 2) and less likely to be interested in general thoracic surgery (5% vs 31%, p < 0.05). Integrated residents were more likely to pursue additional training (66% vs 36%, p < 0.05), including training in congenital heart surgery (22% vs 9%, p < 0.05) and minimally invasive cardiac surgery (13% vs 2%, p < 0.05). More were interested in academic practice (57% vs 44%, p < 0.05). More integrated residents strongly agreed that they would be adequately trained after residency (59% vs 45%, p < 0.05) and adequately prepared for the boards (42% vs 28%, p < 0.05).
Comparison of Residents Interested in Academic vs Private Practice in 2014 Those interested in academic practice had distinct specialty interests (Table 3), including a greater interest in congenital surgery (18% vs 2%, p < 0.05) and less interest in mixed cardiac and thoracic surgery (7% vs 37%, p < 0.05). Similarly, more residents interested in academic surgery were planning on doing additional training (51% vs 32%, p < 0.05), including additional training in congenital heart surgery (18% vs 2%, p < 0.05). There were no differences in debt, residents’ perception of adequacy of training, or preparation for the boards.
Comment
Fig 4. Percentage of job seekers with none (blue line), 1 or 2 (red line), or more than 2 (green line) firm job offers. The p value represents the overall p value comparing all years.
Over the course of the last decade, the field of CTS and CTS education has undergone dramatic changes. This study focused on residents’ career paths and perceptions of their training and the specialty in the context of these changes.
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Fig 5. Graduating residents with debt greater than $200,000. However in 2008 the cutoff was >$150,000 (not >$200,000). Data do not take into account inflation. ADULT CARDIAC
Career Pathways: Increased Specialization and Additional Training Over the years the number of residents entering mixed cardiac/thoracic practices has decreased, with more focusing on cardiac or thoracic surgery and more residents pursuing additional training. During this time the field has become increasingly specialized, requiring specific skill sets and knowledge bases; for example, an endovascular skill set is required in the case of transcatheter aortic valve replacement, and with the increasing array of ventricular assist devices, specific knowledge and experience with individual devices is necessary. Some may argue that the increase in additional training reflects a deficiency in training because graduates do not feel adequately prepared. However, this more likely reflects the complexity and increasing subspecialization of the field such that a base of knowledge is acquired during fellowship and specialized techniques are obtained during periods of additional
training [3]. Indeed, the 2013 data show that the vast majority of residents were pursuing additional training to have a specialty practice, to refine skills learned in their program, or to obtain skills not taught in their program, and only 4% were pursuing additional training because they felt inadequately trained.
Expanding Job Market Although in previous years (2007 to 2008, 2011) 35% to 40% had no job offers by March, that decreased to 20% in the last 3 years. Meanwhile, 30% to 34% had three or more offers compared with 12% in 2008, suggesting an improved job market. However, debt has increased substantially, with 43% graduating with debt exceeding $200,000; this increase in debt remains substantial despite the approximately 29% inflation over the span of the study. Increasing debt does not appear to be influencing residents’ choice of private careers over academic careers.
Perception of the Specialty
Fig 6. Percentage of residents who would recommend cardiothoracic surgery (CTS) to trainees. The p value represents the overall p value comparing all years. For a given variable, data points with different letters were statistically significantly different on post hoc testing, whereas data points with the same letter or no letters were not statistically significantly different. (Blue line, agree; red line, neutral; green line, disagree.)
Since 1994 the number of applicants to traditional CTS fellowships has steadily declined [4]. The reasons behind this decline and potential ways to increase interest in CTS have been extensively discussed [5]. Length of training, job security, lifestyle, and concerns regarding the future of the specialty have been considered contributing factors [4, 6, 7], as highlighted in the initial 2002 TSRA survey polling graduating CTS residents [2]. Potential trainees exposed to cardiothoracic surgeons and fellows satisfied by their career choice will help recruit more to the specialty. Our data show that residents are increasingly satisfied with their career choice: 79% in 2012 would recommend CTS to potential trainees in 2012 compared with 59% in 2009. As in other studies [8, 9], mentorship was key to career choice as well as personal experience and case variety. These results confirm the importance of exposure to the specialty, allowing residents to observe the case variety and find mentorship. For integrated programs, this exposure must occur in medical school or before, hence, the
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Fig 7. Study aids for the in training exam. (Blue line, Thoracic Surgery Residents’ Association (TSRA) Review; red line, Thoracic Surgery Directors’ Association (TSDA) curriculum; green line, Self Education Self Assessment in Thoracic Surgery (SESATS); turquoise line, textbooks; blue line, TSRA clinical scenarios.)
efforts by the Joint Council for Thoracic Surgery Education [6] and national societies to increase exposure of younger students to the field.
Perception of CTS Educational Resources: Increasing Use of TSDA/TSRA Resources and Simulation With the increasing interest in CTS education and efforts to optimize education in light of work-hour restrictions, the Joint Council for Thoracic Surgery Education and TSDA have invested heavily in providing programs with curricular resources. Most recently in August 2013 the thoracic “brain”/“Moodle” was launched, providing a comprehensive system with a wide variety of searchable resources, structured curriculum, and ability for the resident and program to both monitor resident progress. The TSRA has also
Fig 8. Percentage of residents who frequently (blue line), occasionally (red line), or rarely (green line) use simulation. The p value represents the overall p value comparing all years. For a given variable, data points with different letters were statistically significantly different on post hoc testing, whereas data points with the same letter or no letters were not statistically significantly different.
invested heavily in improving educational resources, including publishing the TSRA Review and TSRA Clinical Scenarios. Unfortunately, the survey in 2014 did not include a question querying the residents’ perception of the thoracic “brain”/“Moodle,” but the TSDA curriculum was increasingly used as a study aid for the ITE, as was the TSRA Review, while reliance on Self Education Self Assessment in Thoracic Surgery and textbooks (both online and paper) decreased. Therefore, the educational resources provided by the TSDA/Joint Council for Thoracic Surgery Education and TSRA appear to have found a substantial role in the training of residents. Given the work-hour restrictions and inherent limitations of learning operative techniques in the operating room, attention has turned to simulation as an
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Table 2. Comparison of 2014 Integrated and Traditional Residents
Variable
a
Traditional (n ¼ 200 [69%]) No. (%)
p Value <0.001
47 4 19 4 5 9 0
(53) (5) (22)a (5)a (6) (10) (0)
65 11 16 62 6 39 1
(33) (6) (8)a (31)a (3) (20) (1)
7 19 7 11 3 2 9 30
(8) (22)a (8) (13)a (3) (2) (10) (34)a
15 17 5 4 9 12 10 128
(8) (9)a (3) (2)a (5) (6) (5) (64)a
52 26 8 1 1
(59)a (30)a (9) (1) (1)
89 87 15 9 0
(45)a (44)a (8) (5) (0)
37 41 8 1 1
(42)a (47) (9)a (1) (1)
56 94 45 5 0
(28)a (47) (23)a (3) (0)
25 20 28 15
(28) (23) (32) (17)
77 43 45 35
(39) (22) (23) (17)
<0.001
0.038
0.014
0.27
0.049 50 (57)a 12 (14)a 26 (30)
88 (44)a 51 (26)a 61 (31)
Indicates groups that were significantly different on post hoc testing.
adjunct training tool [10]. The frequent use of simulation by residents has increased from 1% in 2010 to 24% in 2012.
Perceptions Regarding Adequacy of Training and Board Preparation Clearly, resident perception of adequacy of training and, in particular, board preparation is a complex issue. Numerous factors contribute to these perceptions, ranging from the highly publicized decreased board passing rate [11] to actual differences in the level of resident preparedness. A large portion of the onus for
board preparation rests on the resident, who must put in the time and effort to prepare. Preparedness is difficult to quantify, and the data in this study did not link perception to ITE scores, board passing rate, or actual technical competence. Despite these limitations, examining residents’ perceived preparedness is important. The present data indicate there appears to be an improvement in resident perception of adequacy of training over the last several years, although down from a high of 97% in 2003. Perception of preparedness for the boards remains below the level of 2011. Multiple efforts are underway to try to improve resident preparation, and how effective those are
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Interest Adult cardiac Aortic Congenital General thoracic Heart failure Mixed cardiac Other Additional training Aortic Congenital Endovascular Minimally invasive cardiac Minimally invasive thoracic Other Transplant None Adequately trained after residency Strongly agree Agree Neutral Disagree Strongly disagree Adequately prepared for boards Strongly agree Agree Neutral Disagree Strongly disagree Debt <$100,000 $100,000–$200,000 $200,000–$300,000 >$300,000 Practice type Academic Private Undecided
Integrated (n ¼ 88 [31%]) No. (%)
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Table 3. Comparison of Residents Interested in Academic Versus Private Practice From the 2014 Survey
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Variable Interest Adult cardiac Aortic Congenital General thoracic Heart failure Mixed cardiac Other Additional training Aortic Congenital Endovascular Minimally invasive cardiac Minimally invasive thoracic Other Transplant None Adequately trained after residency Strongly agree Agree Neutral Disagree Strongly disagree Adequately prepared for boards Strongly agree Agree Neutral Disagree Strongly disagree Debt <$100,000 $100,000–$200,000 $200,000–$300,000 >300,000 a
Academic (n ¼ 138 [48%]) No. (%)
Private (n ¼ 63 [22%]) No. (%)
Undecided (n ¼ 88 [31%]) No. (%)
P Value <0.001
48 8 25 38 9 10 0
(35) (6) (18)a (28) (7) (7)a (0)
26 3 1 10 0 23 0
(41) (5) (2)a (16) (0) (37)a (0)
38 4 9 18 2 15 1
(44) (5) (10) (21) (2) (17)a (1)
12 25 6 7 6 2 13 67
(9) (18)a (4) (5) (4) (1)a (9) (49)a
4 1 3 3 2 5 2 43
(6) (2)a (5) (5) (3) (8) (3) (68)a
6 10 3 5 4 7 4 48
(7) (12) (3) (6) (5) (8)a (5) (55)
75 53 8 2 0
(54) (38) (6) (1) (0)
31 24 4 4 0
(49) (38) (6) (6) (0)
35 36 11 4 1
(40) (41) (13) (5) (1)
55 62 18 3 0
(40) (45) (13) (2) (0)
16 30 15 2 0
(25) (48) (24) (3) (0)
22 43 20 1 1
(25) (49) (23) (1) (1)
59 29 33 17
(43) (21) (24) (12)
18 13 16 16
(29) (21) (24) (25)
25 21 24 17
(29) (24) (28) (20)
0.058
0.176
0.146
0.162
Indicates groups that were significantly different on post hoc testing.
in improving board pass rates and residents’ perception of their preparedness remains to be seen.
Distinct Populations: Integrated and Traditional Track Residents As anticipated since the advent of integrated 6-year programs, the percentage of respondents in such programs has increased substantially, totaling 28% in 2014. This reflects a paradigm shift, as increasingly cardiothoracic surgeons will be trained using this pathway. The optimization of this training pathway remains very much a work in progress because most programs have not yet graduated a class. Given the increasing proportion of integrated residents, analysis of the 2014 data assessed for differences between integrated and traditional track residents.
Prior studies from single institutions comparing applicants from both tracks reported higher United States Medical Licensing Examination scores and more advanced degrees in integrated applicants [12–14], variables not evaluated in this study. Not surprisingly, given the preponderance of integrated programs that focus on cardiac surgery, in 2014 integrated residents were less likely to be interested in general thoracic surgery and more likely to be interested in congenital heart surgery. In addition, more integrated residents planned on pursuing additional training and academic careers. This is consistent with previous surveys of integrated residents demonstrating a high interest in academic careers (91% to 95%) [9, 15] and plans on additional training (77%) [9, 16]. Given the large number of integrated residents who are still in their junior
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The authors wish to thank Beth Winer for assistance in obtaining data and previous TSRA executive committee members for their leadership in designing and implementing the TSRA ITE surveys.
References 1. Verrier ED. Joint Council on Thoracic Surgical Education: an investment in our future. J Thorac Cardiovasc Surg 2011;141: 318–21. 2. Lee R. Help wanted. Ann Thorac Surg 2003;76:1779–81.
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3. Nguyen TC, Terwelp MD, Stephens EH, et al. Resident perceptions of 2 vs. 3-year cardiothoracic training programs. Ann Thorac Surg 2015: http://dx.doi.org/10.1016/j. athoracsur.2015.01.031 [Epub ahead of print]. 4. Vaporciyan AA, Reed CE, Erikson C, et al. Factors affecting interest in cardiothoracic surgery: survey of North American general surgery residents. J Thorac Cardiovasc Surg 2009;137:1054–62. 5. Chitwood WR Jr, Spray TL, Feins RH, Mack MJ. Mission critical: thoracic surgery education reform. Ann Thorac Surg 2008;86:1061–2. 6. Kim AW, Reddy RM, Higgins RS, Joint Council for Thoracic Surgical Education Subcommittee B, Brightest. “Back to the future”: recruiting the best and brightest into cardiothoracic surgery. J Thorac Cardiovasc Surg 2010;140:503–4. 7. Vaporciyan AA, Yang SC, Baker CJ, Fann JI, Verrier ED. Cardiothoracic surgery residency training: past, present, and future. J Thorac Cardiovasc Surg 2013;146:759–67. 8. Vaporciyan AA, Reed CE, Erikson C, et al. Factors affecting interest in cardiothoracic surgery: survey of North American general surgery residents. Ann Thorac Surg 2009;87:1351–9. 9. Lebastchi AH, Yuh DD. Nationwide survey of us integrated 6-year cardiothoracic surgical residents. J Thorac Cardiovasc Surg 2014;148:401–7. 10. Carpenter AJ, Yang SC, Uhlig PN, Colson YL. Envisioning simulation in the future of thoracic surgical education. J Thorac Cardiovasc Surg 2008;135:477–84. 11. Moffatt-Bruce SD, Ross P, Williams TE Jr. American Board of Thoracic Surgery examination: fewer graduates, more failures. J Thorac Cardiovasc Surg 2014;147:1464–9. 12. Gasparri MG, Tisol WB, Masroor S. Impact of a six-year integrated thoracic surgery training program at the Medical College of Wisconsin. Ann Thorac Surg 2012;93:592–5; discussion 596–7. 13. Varghese TK Jr, Mokadam NA, Verrier ED, Wallyce D, Wood DE. Motivations and demographics of I-6 and traditional 5þ2 cardiothoracic surgery resident applicants: insights from an academic training program. Ann Thorac Surg 2014;98:877–83. 14. Chikwe J, Brewer Z, Goldstone AB, Adams DH. Integrated thoracic residency program applicants: the best and the brightest? Ann Thorac Surg 2011;92:1586–91. 15. Tchantchaleishvili V, Barrus B, Knight PA, Jones CE, Watson TJ, Hicks GL. Six-year integrated cardiothoracic surgery residency applicants: characteristics, expectations, and concerns. J Thorac Cardiovasc Surg 2013;146:753–8. 16. Tchantchaleishvili V, LaPar DJ, Stephens EH, Berfield KS, Odell DD, DeNino WF. Current integrated cardiothoracic surgery residents: a Thoracic Surgery Residents Association survey. Ann Thorac Surg 2015;99:1040–7.
DISCUSSION DR ROBERT S.D. HIGGINS (Columbus, OH): It was very exciting to see your presentation. It was well done, obviously. It is fantastic information that I think everybody in the specialty is interested in hearing. I am thinking about the correlation between the residents’ perception of their preparation for the board and how their preparation has changed in terms of the source of information and what they use to prepare for the exam. We understand that the exam has changed a bit over the last several years, but maybe you can help me understand a little bit more about that correlation. I think it is important. There are others in the audience who think about that correlation. They are all bright people. They all work hard. They are all accomplished. They ought to be able to prepare for the exam. I am trying to figure out where the problem is.
DR STEPHENS: Thank you for an excellent question. It brings up several important points, one of which is that we do not have an association between particular residents who did not feel well prepared and whether they in fact performed more poorly on the oral and/or written boards, and whether their poor performance was specifically on the written or oral boards. Dr Moffatt-Bruce studied both written and oral board pass rates, and over time the written board pass rates started to improve, while the oral board pass rates still struggled, although there was an up-trend. The oral and written boards are two distinct types of examinations in terms of the type of knowledge assessed: the written boards consist more of “book” knowledge, while the oral boards test clinical knowledge and judgment. In terms of specific resources that residents are using, we from the Thoracic Surgery Residents Association (TSRA) are hoping that the clinical
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years, whether these distinctions between the two populations are born out when the integrated residents graduate remain to be seen. The integrated training paradigm remains a work in progress, with ongoing changes in program structure and expectations, and only two graduated classes to date. Some have expressed concern about the adequacy of training in the integrated track, speculating that some residents may require additional training [9]. However, there is also a trend moving toward advanced training as the field becomes more specialized. This study has some limitations. The 2003 and 2006 surveys both had a significantly lower response rate, which could have biased the results. In addition, raw data for 2006 to 2009 were not available, precluding statistical comparison between those and remaining years, which also limits conclusions that can be made regarding change during the last decade. Changes in survey questions and response choices also limited the comparisons. Further, the mandatory nature of the questionnaire may cast doubt on the sincerity and comprehensiveness of residents’ responses. Given the same residents answer the survey every year of their training, the results may be unduly influenced by individual responses. Debt was not adjusted by inflation each year. In summary, with the changes occurring in CTS over the last decade, residents are more satisfied with their career choice and are enjoying increasing job opportunities, with more residents pursuing advanced training.
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scenarios would be helpful in preparation for the oral boards and the Thoracic Surgery Directors’ Association (TSDA) curriculum and TSRA review might be more helpful in terms of “book” knowledge tested in the written boards. These are excellent questions and the Board and the Residency Review Committee (RRC) take the oral and written board pass rates very seriously and are very involved in trying to help residents pass. DR HIGGINS: I would argue that that is an important area for all parties, TSDA, TSRA, and the Board, to think about the linkage between what materials and what curricular activities and what oral board preparation occurs and how that will affect the resident’s confidence in pursuing those milestones. It is really important. DR STEPHENS: Right, and we did not look at whether certain resources actually provided better preparation than other resources. DR PAUL H. SCHIPPER (Portland, OR): I am building an Integrated-6 (I-6) program, and one of the things I am trying to roll into that is the cardiac track and the thoracic track. You have these levels of interest for adult cardiac, congenital, general thoracic, heart failure. I am curious to know if you have data looking across the integrated tracks to see if those percentages change from the first year to the second year and third year. DR STEPHENS: That is something we have not looked at: stratifying by year; even talking to fellow residents as they move through, their interests change. I should also point out that this polling does not take into account their ultimate career choice. Someone coming in as an intern, as an I-6, might say they are interested in congenital heart surgery and then they get to be a postgraduate year 4 and they decide to do adult cardiac, or they might say they are interested in an academic career, but do they actually pursue an academic career? Do they get an academic job? That is something that we have not looked at. DR JOHN DAVID VEGA (Atlanta, GA): There is a large discrepancy between the number of applicants for I-6 positions and the actual positions available. Do we have any data yet on what those I-6 individuals do who do not get into an Integrated-6 program? Are they still interested in cardiothoracic surgery?
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Depending on the answer, that implies: Are you passionate about cardiothoracic, are you going to do it regardless of whether it takes you 6 years or 10 years, or are you just interested in it if you can do it in 6 years because it is sexy, etc? DR STEPHENS: That is an excellent point. I am not aware of any data. I do not know if Dr Vaporciyan is. DR ARA A. VAPORCIYAN (Houston, TX): You cannot get that data directly from the National Resident Matching Program (NRMP), but what the I-6 programs and the I-6 committee have done is they have asked the applicants if it would be okay if we could contact them later, and then they are trying to pull together resources. So each I-6 program is writing down everybody they interviewed and sending it centrally to Beth Winer, and then she is sort of trying to figure out the total applicant pool so that we can reach out to them. DR VEGA: They should know. I mean they are registering for a match, right? DR VAPORCIYAN: Correct. DR VEGA: So that data should be there in terms of individuals. You just have to track them. DR VAPORCIYAN: Yes, but we cannot access that from the NRMP. We cannot get that from them. DR HIGGINS: And the other thing, David, is that it could be 5 years later. DR VEGA: Yes, I understand they are several years down the road. I think it is important data to know. DR VAPORCIYAN: Absolutely, although I think we are seeing an uptake this year in applicants. I have not seen the numbers, but just gauging my discussions across this meeting, there are many more applicants for the traditional programs than there have been in the last few years, and the timing, considering that the I-6 programs have been around for about 7 years now, is about right for these people to be maturing through a general surgery path and maintaining that interest. I do not know.