- Email: [email protected]
Predictors of Career Choice Among Cardiothoracic Surgery Trainees
Predictors of Career Choice Among Cardiothoracic Surgery Trainees
University of Rochester Medical Center, Rochester, New York; University of Virginia, Charlottesville, Virginia; University of Pittsburgh, Pittsburgh, Pennsylvania; Emory University, Atlanta, Georgia; Cleveland Clinic Foundation, Cleveland, Ohio; University of Washington, Seattle, Washington; University of Texas Health Science Center at San Antonio, San Antonio, Texas; Baylor College of Medicine, Houston, Texas; Pinnacle Health CardioVascular Institute, Harrisbsurg, Pennsylvania; Duke University Medical Center, Durham, North Carolina; Northwestern University, Chicago, Illinois; Columbia University, New York, New York; Massachusetts General Hospital, Boston, Massachusetts; Medical University of South Carolina, Charleston, South Carolina; and Memorial Hermann Hospital–Heart and Vascular Institute, University of Texas Medical School at Houston, Houston, Texas
Background. The impact of factors influencing career choice by cardiothoracic surgery (CTS) trainees remains poorly defined in the modern era. We sought to examine the associations between CTS trainee characteristics and future career aspirations. Methods. The 2012 Thoracic Surgery In-Training Examination survey results were used to categorize responders according to career interest: congenital, adult cardiac, mixed cardiac/thoracic, and general thoracic surgery. Univariate and multivariable analyses were used to identify and analyze characteristics associated with career interest categories. Results. With a 100% response rate, 300 responses from trainees in programs accredited by the Accreditation Council for Graduate Medical Education were included in the analysis. Multinomial logistic regression identified three factors associated with career choice in CTS: level of training (p < 0.001), type of training pathway (p < 0.001), and primary motivating factor to pursue CTS (p [ 0.002). Trainees interested in general thoracic surgery were more
likely to commit to CTS during their senior years of general surgery training and were more likely to enroll in 2-year or 3-year traditional fellowships, whereas individuals pursuing adult or congenital cardiac surgery were more likely to commit earlier during training and were more commonly interested in 6-year integrated or joint training pathways. Moreover, trainees interested in general thoracic surgery were predominantly influenced by early mentorship (p [ 0.025 vs adult cardiac), and trainees interested in adult cardiac surgery were more likely to be influenced by types of operations (p [ 0.047 vs general thoracic). Conclusions. Career choice in CTS appears strongly associated with level of training, exposure to mentors, and training paradigm. These results demonstrate the importance of maintaining all four currently approved training pathways to retain balance and diversity in future CTS practices.
E
[1]. Among applicants to 6-year integrated (I-6) CTS programs, there is a disproportionately high interest in cardiac surgery compared with general thoracic surgery [2–4]. Despite our awareness of this phenomenon, little is known about the factors associated with these differences. If we gain a better understanding of these factors, we may be able to better meet the individual educational needs of our CTS trainees. As such, the Thoracic Surgery Residents Association (TSRA) sought to examine the
ven though cardiothoracic surgery (CTS) is a single board specialty requiring unified training, it is well known that cardiac-oriented and thoracic-oriented individuals represent two very different groups of trainees that have unique educational needs. The differentiation between trainees interested in cardiac surgery and trainees interested in general thoracic surgery may occur early in the course of medical education or even before
(Ann Thorac Surg 2015;100:1849–54) Ó 2015 by The Society of Thoracic Surgeons
Accepted for publication April 7, 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, University of Texas Houston– Memorial Hermann, 6400 Fannin, Ste 2850, Houston, TX 77030; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
The Appendix can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2015. 04.073] on http://www.annalsthoracicsurgery.org.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.04.073
GENERAL THORACIC
Vakhtang Tchantchaleishvili, MD, Damien J. LaPar, MD, MS, David D. Odell, MD, MMSc, William Stein, MD, Muhammad Aftab, MD, Kathleen S. Berfield, MD, Amanda L. Eilers, DO, Shawn S. Groth, MD, MS, John F. Lazar, MD, Michael P. Robich, MD, MSPH, Asad A. Shah, MD, Danielle A. Smith, MD, Elizabeth H. Stephens, MD, PhD, Cameron T. Stock, MD, Walter F. DeNino, MD, and Tom C. Nguyen, MD
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associations between the characteristics of CTS trainees and their future career aspirations. To our knowledge, this represents the first attempt to identify factors delineating cardiac-oriented and thoracic-oriented groups among all currently available training paradigms.
GENERAL THORACIC
Material and Methods As a result of the work of Richard Lee [5], the first TSRA survey was conducted in 2003. Starting in 2006, CTS residents enrolled in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) are required to take a 30-question survey designed by the TRSA and the Thoracic Surgery Directors Association (TSDA) before taking the annual in-training examination, and starting in 2007, the survey has been mandatory, with a 100% response rate [6]. The development of these surveys has been previously described in detail [7, 8]. The TSRA and TSDA executive committees evaluate the survey and add, remove, or modify questions as needed on an annual basis. The 2012 survey had the most questions that were relevant to our study and consequently was selected for analysis. The trainees in ACGME-accredited programs belonged to one of four training pathways: I-6, joint training (4þ3), or either 2-year (2Y) or 3-year (3Y) traditional fellowship programs. Responses from trainees in nonaccredited programs (eg, super-fellowships, foreign-trained) were not included. The responses were categorized according to career interest: congenital cardiac (CC), adult cardiac (AC), mixed cardiac/thoracic (MCT), and general thoracic surgery (GT). Residents’ characteristics relevant to the career interest were selected as initial candidate variables. Of note, information on age and gender was not available in the survey. The candidate variables were subjected to multinomial logistic regression wherein the outcome variable (career interest) had four levels (CC, AC, MCT, GT). Backward stepwise elimination of candidate variables was performed based on the Akaike information criterion [9] to determine the best fitted model. Predictors in the final model were selected for further analysis. A c2 test was used to compare categorical variables, and pairwise comparison of proportions was used for posthoc testing. Ordinal variables were analyzed by the Kruskal-Wallis test. A two-sided p value of < 0.05 was considered statistically significant. R software, version 3.0.1 (R Foundation for Statistical Computing, Vienna, Austria) was used for statistical analysis.
Results With a 100% response rate, 313 total trainees completed the survey. Of those, 300 responders were in ACGMEaccredited CTS programs and were included in the analysis. The majority of the responders were in 2Y (44%, n ¼ 132) and 3Y (34%, n ¼ 102) programs. The remaining responders were from 4þ3 (5%, n ¼15) and I-6 (17%, n ¼ 51) programs. Postgraduate years (PGY) ranged from
Ann Thorac Surg 2015;100:1849–54
PGY 1 to PGY 10 and above. The age and gender of trainees was not available for demographic analysis. Career interest was distributed as follows: 114 AC (38%), 86 MCT (28.7%), 70 GTS (23.3%, and 30 CC (10%). Multinomial logistic regression identified three factors linked with career choice: level of training, type of CTS training pathway, and motivating factors to pursue CTS.
Level of Training Level of training was significantly linked to career choice in CTS (Table 1, Fig 1). Nearly half (48%) of the responders made a decision to pursue CTS before (22.3%, n ¼ 67) or during (26.0%, n ¼ 78) medical school. This group was more likely to be interested in congenital or adult cardiac surgery (before medical school, CC 19.9% and AC 46.3%; and during medical school, CC 11.5% and AC 50%). Among trainees interested in GT, they were less likely to choose CTS before (GT 13.4%) or during (GT 10.3%) medical school. Interest in GT was much higher in individuals who decided to pursue CTS during general surgery (GS) residency, especially in its senior years (GS PGY 3–4, 35.9%; GS PGY 5, 37.5%). Interest in MCT was highest in this group as well (GS PGY 3–4, 37.9%; GS PGY 5, 37.5%), whereas interest in congenital and adult cardiac surgery was less (GS PGY 3–4, CC 1.9% and AC 24.3%; GS PGY 5, CC 12.5% and CAC 12.5%).
Training Pathway Training pathway was significantly linked to career preference (Table 1, Fig 2). Responders in 4þ3 and I-6 programs represented the majority of trainees interested in CC and AC (4þ3: CC 26.7% and AC 46.7%; I-6: CC 19.6% and AC 52.9%) and included the least number of residents interested in general thoracic surgery (4þ3: GT 13.3%; I-6: GT 5.9%). By contrast, 2Y and 3Y trainees had significantly higher interest in GT (2Y 35.6%, 3Y 17.6%) and reduced interest in congenital cardiac surgery (2Y 6.1%, 3Y 7.8%). Interest in AC was less but remained considerable (2Y 31.8%, 3Y 37.3%). Post-hoc analysis (for individual comparison, see Appendix) identified I-6 and 2Y pathways as the marginal groups with the largest differences (I-6: AC vs GT, p ¼ 0.006, CC vs GT, p ¼ 0.002; 2Y: AC vs GT, p ¼ 0.001, CC vs GT, p ¼ 0.002).
Motivating Factors The most frequently reported primary motivating factors to pursue CTS were types of cases (43%, n ¼ 129), mentorship (27.3%, n ¼ 82), and personal experience (24.7%, n ¼ 74) (Table 1, Fig 3). Less frequently quoted factors included critical care exposure, challenging specialty, anatomy, cardiopulmonary physiology, and length of training (overall 5%, n ¼ 15). Post-hoc analysis identified two factors contributing to overall statistical significance. For GT, the most important factor was mentorship (p ¼ 0.025, GT vs AC; p ¼ 0.03, GT vs MCT), and for AC, types of cases was the most
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Table 1. Career Interest by Decision Time, Training Pathway, and Primary Motivating Factor Primary Interest Factor
Congenital Cardiac Adult Cardiac Mixed Cardiac and Thoracic General Thoracic (n ¼ 30) (n ¼ 114) (n ¼ 86) (n ¼ 70) p Value
a
<0.001 1 2 5 9 13
(12.5%) (1.9%) (11.4%) (11.5%) (19.4)
1 25 18 39 31
(12.5%) (24.3%) (40.9%) (50.0%) (46.3%)
3 39 8 22 14
(37.5%) (37.9%) (18.2%) (28.2%) (20.9%)
3 37 13 8 9
(37.5%) (35.9%) (29.5%) (10.3%) (13.4%)
8 8 4 10
(6.1%) (7.8%) (26.7%) (19.6%)
42 38 7 27
(31.8%) (37.3%) (46.7%) (52.9%)
35 38 2 11
(26.5%) (37.3%) (13.3%) (21.6%)
47 18 2 3
(35.6%) (17.6%) (13.3%) (5.9%)
6 13 8 3
(7.3%) (10.1%) (10.8%) (20.0%) 1 1 0 0 1 0
28 60 21 5
(34.1%) (46.5%) (28.4%) (33.3%) 4 0 0 0 0 1
16 34 30 6
(19.5%) (26.4%) (40.5%) (40.0%) 3 1 1 1 0 0
32 22 15 1
(39.0%) (17.1%) (20.3%) (6.7%) 1 0 0 0 0 0
<0.001
0.002
Responses with n < 10 are grouped together.
the majority in this group (43.3%, n ¼ 13) selected types of cases as most important.
important determining factor (p ¼ 0.047, AC vs GT). As such, mentorship influenced the decision making primarily in favor of GT (39.0%, n ¼ 32), and types of cases influenced the decision in favor of AC (46.5%, n ¼ 60). No significant predictors were identified for CC; however,
Comment
Fig 1. Difference in primary interest by level of training.
Although factors affecting interest in CTS as a whole specialty have been studied in the past [10], this study represents the first attempt to address the decision in career choice between specific fields of CTS. Our results demonstrated a difference in distribution of interests in AC/CC versus GT based on the trainee’s level of medical education. Trainees interested in AC or CC were most likely to make their career choice before or during medical school, whereas trainees interested in GT were more likely to make their career choice during GS training. More than half of the responders decided about their career choice during GS residency, emphasizing the importance of maintaining the traditional pathway. All four training pathways (2Y, 3Y, 4þ3, I-6) had a considerable proportion of individuals interested in AC. Nonetheless, those in I-6 and 4þ3 programs clearly had the greatest preference for AC (I-6 52.9%, 4þ3 46.7%). By contrast, individuals interested in GT were more attracted to the traditional training model, especially 2Y programs. This trend was also noted in another study by the TSRA that compared various aspects of 2Y versus 3Y training programs and found, although it was not statistically significant, that 3Y training programs had more cardiac-
GENERAL THORACIC
Decision time General surgery year 5 (n ¼ 8) General surgery years 3–4 (n ¼ (103) General surgery years 1–2 (n ¼ 44) During medical school (n ¼ 78) Before medical school (n ¼ 67) Training pathway 2-year standard (n ¼ 132) 3-year standard (n ¼ 102) 4þ3 standard (n ¼ 15) 6-year integrated (n ¼ 51) Primary motivating factor Mentorship (n ¼ 82) Types of cases (n ¼ 129) Personal experience (n ¼ 74) Other (n ¼ 15)a Critical care exposure (9) Challenging (2) Anatomy (1) Cardipulmonary physiology (1) Length of training (1) Little bit of all of the above (1)
TCHANTCHALEISHVILI ET AL CAREER CHOICE PREDICTORS IN CTS TRAINEES
GENERAL THORACIC
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Fig 2. Difference in primary interest by training program type.
oriented and 2Y programs more thoracic-oriented individuals [11]. Even though it was a categoric variable, program type could be ordered based on time balance between general surgery and cardiac surgery. In this case, it would follow that cardiac-oriented individuals may be attracted to doing as little general surgery and as much cardiac surgery as possible (I-6 programs). By contrast, more general surgery and less cardiac surgery (2Y programs) may appeal to GT-oriented individuals. These differences in
Ann Thorac Surg 2015;100:1849–54
pathway type affect GT more significantly than AC/CC because there is a sizable proportion of cardiac-oriented individuals in every pathway. It should be noted that, traditionally, most I-6 and 4þ3 programs have been cardiac-oriented programs, which could create a selection bias. Alternatively, as suggested previously [1], GT-oriented individuals may be selfselecting out of I-6 programs in favor of a more robust general surgery experience. This may in particular apply to operations on the foregut where completing full general surgery residency may provide the trainee with a better skillset. Because I-6 programs are new, it may be too early to tell, and this may be how the early I-6 process is evolving. Still, our findings show the importance of traditional pathways [12] in producing graduates who will in fact practice GT. The primary motivating factor for career choice should by definition be considered a predictor. Interestingly however, the post-hoc analysis showed that only a fraction of these factors was actually predictive. Specifically, mentorship was the primary influencing factor for thoracic-oriented individuals, whereas types of cases held the most influence for cardiac-oriented individuals. One explanation is that the further along an individual is in training, the more likely the trainee is to be exposed to CTS mentors. It follows that individuals who have not even entered medical school are less likely to have exposure to CTS mentors. This is an important issue because even a brief involvement of a surgeon can influence the career choices of this population [13]—an effect that can be equally extrapolated to both AC/CC and GT. Also, most GS residency programs still have GT rotations but fewer AC rotations that may translate into selectively higher exposure to GT. Of note, Vaporciyan and colleagues [10] previously showed that with increasing length of the CTS rotation, the GS residents were more likely to commit to CTS and to agree that CTS faculty acted as role models and took an interest in their careers. However, no specific comparisons were made to delineate the differences between AC and GT. It has to be mentioned that whatever the current difference in exposure between AC and GT, it may change as the requirement for GT is dropped from general surgery. Although no specific factor was identified for congenital cardiac surgery, this is likely due to the small total number of individuals interested in the field and therefore does not reach statistical significance. Overall, the CC subset statistically behaved more like the AC than the GT subset. Statistically speaking, the MCT group does not appear to have differing characteristics. It is rather an “average” of the features of the cardiac-oriented and thoracicoriented groups, as demonstrated in Figures 1 through 3.
Limitations
Fig 3. Difference in primary interest by factors contributing to the decision. (AC ¼ adult cardiac; CC ¼ congenital cardiac; GT ¼ general thoracic; MCT ¼ mixed cardiac and thoracic.)
Career choice is a complex decision process and involves many possible factors (eg, age, gender, ethnicity, parental influence, USMLE scores) that were neither included in nor detected by the TSRA survey and our study. For example, the survey did not contain information on
Ann Thorac Surg 2015;100:1849–54
responders’ age and gender, which was previously shown to be an influence on overall career choice [14]. The survey was not devised with the goal to address the question of career choice. The results only provide a “snapshot” with no longitudinal analysis. Overall, although this study shows the current landscape (“what is happening”), it does not address the causality (“why it is happening”). Still, our results clearly show an important trend. Why this is so will be subject to future TSRA studies.
Conclusions
References 1. Tchantchaleishvili V, Hicks GL. Should integrated residency programs supplant traditional programs in cardiothoracic surgery? J Thorac Cardiovasc Surg 2014;148:379–80. 2. 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. 3. Lebastchi AH, Yuh DD. Nationwide survey of US integrated 6-year cardiothoracic surgical residents. J Thorac Cardiovasc Surg 2014;148:401–7.
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4. Tchantchaleishvili V, Lapar D, Stephens E, Odell D, DeNino W. Current integrated cardiothoracic surgery residents: a thoracic surgery residents association survey. Ann Thorac Surg 2015;99:1040–7. 5. Lee R. Help wanted. Ann Thorac Surg 2003;76:1779–81. 6. Stephens EH, Odell D, Stein W, et al. A decade of change: training and career paths of cardiothoracic surgery residents 2003 to 2014. Ann Thorac Surg 2015;100:1305–14. 7. Salazar JD, Lee R, Wheatley GH III, Doty JR. Are there enough jobs in cardiothoracic surgery? The Thoracic Surgery Residents Association job placement survey for finishing residents. Ann Thorac Surg 2004;78:1523–7. 8. Cooke DT, Kerendi F, Mettler BA, et al. Update on cardiothoracic surgery resident job opportunities. Ann Thorac Surg 2010;89:1853–9. 9. Akaike H. A new look at the statistical model identification. IEEE Trans Autom Control 1974;19:716–23. 10. 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. 11. Nguyen TC, Terwelp MD, Stephens EH, et al. Resident perceptions of 2 vs. 3-year cardiothoracic training programs. Ann Thorac Surg 2015;99:2070–6. 12. Sainathan S. Integrated thoracic residency: the only pathway of thoracic surgery training in the future? Ann Thorac Surg 2012;94:1374. 13. Kozar RA, Lucci A, Miller CC, et al. Brief intervention by surgeons can influence students toward a career in surgery. J Surg Res 2003;111:166–9. 14. Sanfey HA, Saalwachter-Schulman AR, Nyhof-Young JM, Eidelson B, Mann BD. Influences on medical student career choice: gender or generation? Arch Surg 2006;141:1086–94; discussion 1094.
DISCUSSION DR THOMAS WATSON (Rochester, NY): V.T., great job. The data are enlightening and support what a lot of us general thoracic surgeons fear: that the move from a traditional pathway to an integrated training paradigm will dry up the supply of well-trained thoracic surgeons. You suggest that we need to keep the traditional pathways open, but, unfortunately, that is a financial challenge for a lot of institutions. For instance, we have had to close our traditional paradigm because we have gone to funding the integrated program. So that may not be the right answer. Why do you think it is that medical students are interested in cardiac surgery and not thoracic surgery, and what can we do to get medical students more interested in thoracic surgery as another solution to this potential workforce issue? DR TCHANTCHALEISHVILI: This is a difficult question to answer. To me, general thoracic surgery is an intellectual specialty. It takes more exposure and experience, often found during general surgery residency, to fully appreciate its extent and magnitude. Cardiac surgery has a definite allure and seems to speak to people at an early stage of training. It is not unusual for these individuals to start dreaming of becoming cardiac surgeons before starting medical school. However with experience, it is foreseeable that a proportion of integrated residents will elect careers in general thoracic surgery. DR ARA A. VAPORCIYAN (Houston, TX): For us, we draw the largest group from those who wanted to be a surgical oncologist,
and then midway through general surgery they decide that thoracic gives them the surgical oncology, but also different procedures are enticing. I think that is where we see a large group of them. After they have rotated a few times on surgical oncology and like it, then suddenly they transition over. I agree with you that it is going to get difficult. If you are funding six full-time equivalents, they are going to be hard-pressed to give you two more full-time equivalents to maintain a traditional pathway. DR SAMUEL WEINSTEIN (New York, NY): I want to congratulate you on an excellent and interesting presentation. I have two questions. We have noticed the same trend that you described: that with our traditional pathway, the independent program, we have twice as many applicants now as we had 2 years ago, and roughly half of them are interested or declare themselves in noncardiac chest surgery. While you said that you didn’t have causality in your data, could you postulate why you think that is? Two, as I start to debate with my colleagues our decision to proceed or not to proceed with an integrated program, based on what you have seen, should we proceed or stick with what we have? DR TCHANTCHALEISHVILI: The survey was not devised to answer this question. The analysis only determines an association. We cannot say that one or the other factor is the cause of what is happening. Regarding your second question, I think it is important to keep all four pathways and not to restrict ourselves
GENERAL THORACIC
The findings of our study clearly outline interesting points that career choice in CTS appears strongly associated with level of training, exposure to mentors, and training paradigm. This bears significant implications on maintaining all training pathways open. Further studies are necessary to validate the findings.
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to a single one. This will provide diversity in the spectrum of training open to those in medical school and residency.
GENERAL THORACIC
DR MEGHANA HELDER (Rochester, MN): Traditional track fellows seem to be choosing general thoracic surgery over cardiac surgery. Also, general surgery residency programs have moved away from any time in cardiac surgery for their residents. Are there any questions in the survey that talk about experience in residency programs, as far as months of cardiac surgery or months of thoracic surgery, that you could draw from for causality there? DR TCHANTCHALEISHVILI: No, we did not have this information for analysis. However, it is well known that general surgery residents routinely rotate on general thoracic surgery services, but only a small fraction of them rotate on cardiac surgery. DR ANTHONY W. KIM (New Haven, CT): Your presentation was excellent. Did your survey instrument give you a chance to get a sense of any sort of crossover from one subspecialty to another? The reason I ask this question is because I noticed that you had four categories but did not include an undecided or undeclared group. DR TCHANTCHALEISHVILI: No, the survey questionnaire did not include this information. DR PAUL H. SCHIPPER (Portland, OR): I’m curious how mentorship rose to the top in driving the decision for general thoracic. How was that question asked in the survey? Was this
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a write-in thing? Were there other possibilities that they could also have chosen from that were not driving factors in this decision? DR TCHANTCHALEISHVILI: The question in the survey was “What was the most important factor that influenced the decision?” and one of the choices was mentorship. Just to emphasize, it was mentorship at the time of the decision, not at the time of our survey. Of note, in the survey there was another question: “Do you have a mentor? yes or no.” This question addressed having a mentor at the time of the survey, but the question was eliminated as a statistically insignificant predictor because both cardiac and thoracic trainees were mentored equally. What we think is happening is that medical students or individuals before medical school, who decide to be cardiac surgeons, do so without having a cardiac surgeon mentoring them. On the other hand, general surgery residents who have exposure to thoracic surgeons are mentored and encouraged to pursue that specialty. DR SCHIPPER: What were the other choices that mentorship may have beaten out? DR TCHANTCHALEISHVILI: Other choices besides mentorship included types of cases, personal experience, and an “other” option where respondents could enter free text. The individuals who chose the “other” free text option represented a smaller group. Free text answers included intensive care unit experience, cardiovascular physiology, and length of training, among others. These answers were grouped together for statistical analysis. The post-hoc analysis showed only mentorship and types of cases as being significant.
University of Rochester Medical Center, Rochester, New York; University of Virginia, Charlottesville, Virginia; University of Pittsburgh, Pittsburgh, Pennsylvania; Emory University, Atlanta, Georgia; Cleveland Clinic Foundation, Cleveland, Ohio; University of Washington, Seattle, Washington; University of Texas Health Science Center at San Antonio, San Antonio, Texas; Baylor College of Medicine, Houston, Texas; Pinnacle Health CardioVascular Institute, Harrisbsurg, Pennsylvania; Duke University Medical Center, Durham, North Carolina; Northwestern University, Chicago, Illinois; Columbia University, New York, New York; Massachusetts General Hospital, Boston, Massachusetts; Medical University of South Carolina, Charleston, South Carolina; and Memorial Hermann Hospital–Heart and Vascular Institute, University of Texas Medical School at Houston, Houston, Texas
Background. The impact of factors influencing career choice by cardiothoracic surgery (CTS) trainees remains poorly defined in the modern era. We sought to examine the associations between CTS trainee characteristics and future career aspirations. Methods. The 2012 Thoracic Surgery In-Training Examination survey results were used to categorize responders according to career interest: congenital, adult cardiac, mixed cardiac/thoracic, and general thoracic surgery. Univariate and multivariable analyses were used to identify and analyze characteristics associated with career interest categories. Results. With a 100% response rate, 300 responses from trainees in programs accredited by the Accreditation Council for Graduate Medical Education were included in the analysis. Multinomial logistic regression identified three factors associated with career choice in CTS: level of training (p < 0.001), type of training pathway (p < 0.001), and primary motivating factor to pursue CTS (p [ 0.002). Trainees interested in general thoracic surgery were more
likely to commit to CTS during their senior years of general surgery training and were more likely to enroll in 2-year or 3-year traditional fellowships, whereas individuals pursuing adult or congenital cardiac surgery were more likely to commit earlier during training and were more commonly interested in 6-year integrated or joint training pathways. Moreover, trainees interested in general thoracic surgery were predominantly influenced by early mentorship (p [ 0.025 vs adult cardiac), and trainees interested in adult cardiac surgery were more likely to be influenced by types of operations (p [ 0.047 vs general thoracic). Conclusions. Career choice in CTS appears strongly associated with level of training, exposure to mentors, and training paradigm. These results demonstrate the importance of maintaining all four currently approved training pathways to retain balance and diversity in future CTS practices.
E
[1]. Among applicants to 6-year integrated (I-6) CTS programs, there is a disproportionately high interest in cardiac surgery compared with general thoracic surgery [2–4]. Despite our awareness of this phenomenon, little is known about the factors associated with these differences. If we gain a better understanding of these factors, we may be able to better meet the individual educational needs of our CTS trainees. As such, the Thoracic Surgery Residents Association (TSRA) sought to examine the
ven though cardiothoracic surgery (CTS) is a single board specialty requiring unified training, it is well known that cardiac-oriented and thoracic-oriented individuals represent two very different groups of trainees that have unique educational needs. The differentiation between trainees interested in cardiac surgery and trainees interested in general thoracic surgery may occur early in the course of medical education or even before
(Ann Thorac Surg 2015;100:1849–54) Ó 2015 by The Society of Thoracic Surgeons
Accepted for publication April 7, 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, University of Texas Houston– Memorial Hermann, 6400 Fannin, Ste 2850, Houston, TX 77030; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
The Appendix can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2015. 04.073] on http://www.annalsthoracicsurgery.org.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.04.073
GENERAL THORACIC
Vakhtang Tchantchaleishvili, MD, Damien J. LaPar, MD, MS, David D. Odell, MD, MMSc, William Stein, MD, Muhammad Aftab, MD, Kathleen S. Berfield, MD, Amanda L. Eilers, DO, Shawn S. Groth, MD, MS, John F. Lazar, MD, Michael P. Robich, MD, MSPH, Asad A. Shah, MD, Danielle A. Smith, MD, Elizabeth H. Stephens, MD, PhD, Cameron T. Stock, MD, Walter F. DeNino, MD, and Tom C. Nguyen, MD
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associations between the characteristics of CTS trainees and their future career aspirations. To our knowledge, this represents the first attempt to identify factors delineating cardiac-oriented and thoracic-oriented groups among all currently available training paradigms.
GENERAL THORACIC
Material and Methods As a result of the work of Richard Lee [5], the first TSRA survey was conducted in 2003. Starting in 2006, CTS residents enrolled in programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) are required to take a 30-question survey designed by the TRSA and the Thoracic Surgery Directors Association (TSDA) before taking the annual in-training examination, and starting in 2007, the survey has been mandatory, with a 100% response rate [6]. The development of these surveys has been previously described in detail [7, 8]. The TSRA and TSDA executive committees evaluate the survey and add, remove, or modify questions as needed on an annual basis. The 2012 survey had the most questions that were relevant to our study and consequently was selected for analysis. The trainees in ACGME-accredited programs belonged to one of four training pathways: I-6, joint training (4þ3), or either 2-year (2Y) or 3-year (3Y) traditional fellowship programs. Responses from trainees in nonaccredited programs (eg, super-fellowships, foreign-trained) were not included. The responses were categorized according to career interest: congenital cardiac (CC), adult cardiac (AC), mixed cardiac/thoracic (MCT), and general thoracic surgery (GT). Residents’ characteristics relevant to the career interest were selected as initial candidate variables. Of note, information on age and gender was not available in the survey. The candidate variables were subjected to multinomial logistic regression wherein the outcome variable (career interest) had four levels (CC, AC, MCT, GT). Backward stepwise elimination of candidate variables was performed based on the Akaike information criterion [9] to determine the best fitted model. Predictors in the final model were selected for further analysis. A c2 test was used to compare categorical variables, and pairwise comparison of proportions was used for posthoc testing. Ordinal variables were analyzed by the Kruskal-Wallis test. A two-sided p value of < 0.05 was considered statistically significant. R software, version 3.0.1 (R Foundation for Statistical Computing, Vienna, Austria) was used for statistical analysis.
Results With a 100% response rate, 313 total trainees completed the survey. Of those, 300 responders were in ACGMEaccredited CTS programs and were included in the analysis. The majority of the responders were in 2Y (44%, n ¼ 132) and 3Y (34%, n ¼ 102) programs. The remaining responders were from 4þ3 (5%, n ¼15) and I-6 (17%, n ¼ 51) programs. Postgraduate years (PGY) ranged from
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PGY 1 to PGY 10 and above. The age and gender of trainees was not available for demographic analysis. Career interest was distributed as follows: 114 AC (38%), 86 MCT (28.7%), 70 GTS (23.3%, and 30 CC (10%). Multinomial logistic regression identified three factors linked with career choice: level of training, type of CTS training pathway, and motivating factors to pursue CTS.
Level of Training Level of training was significantly linked to career choice in CTS (Table 1, Fig 1). Nearly half (48%) of the responders made a decision to pursue CTS before (22.3%, n ¼ 67) or during (26.0%, n ¼ 78) medical school. This group was more likely to be interested in congenital or adult cardiac surgery (before medical school, CC 19.9% and AC 46.3%; and during medical school, CC 11.5% and AC 50%). Among trainees interested in GT, they were less likely to choose CTS before (GT 13.4%) or during (GT 10.3%) medical school. Interest in GT was much higher in individuals who decided to pursue CTS during general surgery (GS) residency, especially in its senior years (GS PGY 3–4, 35.9%; GS PGY 5, 37.5%). Interest in MCT was highest in this group as well (GS PGY 3–4, 37.9%; GS PGY 5, 37.5%), whereas interest in congenital and adult cardiac surgery was less (GS PGY 3–4, CC 1.9% and AC 24.3%; GS PGY 5, CC 12.5% and CAC 12.5%).
Training Pathway Training pathway was significantly linked to career preference (Table 1, Fig 2). Responders in 4þ3 and I-6 programs represented the majority of trainees interested in CC and AC (4þ3: CC 26.7% and AC 46.7%; I-6: CC 19.6% and AC 52.9%) and included the least number of residents interested in general thoracic surgery (4þ3: GT 13.3%; I-6: GT 5.9%). By contrast, 2Y and 3Y trainees had significantly higher interest in GT (2Y 35.6%, 3Y 17.6%) and reduced interest in congenital cardiac surgery (2Y 6.1%, 3Y 7.8%). Interest in AC was less but remained considerable (2Y 31.8%, 3Y 37.3%). Post-hoc analysis (for individual comparison, see Appendix) identified I-6 and 2Y pathways as the marginal groups with the largest differences (I-6: AC vs GT, p ¼ 0.006, CC vs GT, p ¼ 0.002; 2Y: AC vs GT, p ¼ 0.001, CC vs GT, p ¼ 0.002).
Motivating Factors The most frequently reported primary motivating factors to pursue CTS were types of cases (43%, n ¼ 129), mentorship (27.3%, n ¼ 82), and personal experience (24.7%, n ¼ 74) (Table 1, Fig 3). Less frequently quoted factors included critical care exposure, challenging specialty, anatomy, cardiopulmonary physiology, and length of training (overall 5%, n ¼ 15). Post-hoc analysis identified two factors contributing to overall statistical significance. For GT, the most important factor was mentorship (p ¼ 0.025, GT vs AC; p ¼ 0.03, GT vs MCT), and for AC, types of cases was the most
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Table 1. Career Interest by Decision Time, Training Pathway, and Primary Motivating Factor Primary Interest Factor
Congenital Cardiac Adult Cardiac Mixed Cardiac and Thoracic General Thoracic (n ¼ 30) (n ¼ 114) (n ¼ 86) (n ¼ 70) p Value
a
<0.001 1 2 5 9 13
(12.5%) (1.9%) (11.4%) (11.5%) (19.4)
1 25 18 39 31
(12.5%) (24.3%) (40.9%) (50.0%) (46.3%)
3 39 8 22 14
(37.5%) (37.9%) (18.2%) (28.2%) (20.9%)
3 37 13 8 9
(37.5%) (35.9%) (29.5%) (10.3%) (13.4%)
8 8 4 10
(6.1%) (7.8%) (26.7%) (19.6%)
42 38 7 27
(31.8%) (37.3%) (46.7%) (52.9%)
35 38 2 11
(26.5%) (37.3%) (13.3%) (21.6%)
47 18 2 3
(35.6%) (17.6%) (13.3%) (5.9%)
6 13 8 3
(7.3%) (10.1%) (10.8%) (20.0%) 1 1 0 0 1 0
28 60 21 5
(34.1%) (46.5%) (28.4%) (33.3%) 4 0 0 0 0 1
16 34 30 6
(19.5%) (26.4%) (40.5%) (40.0%) 3 1 1 1 0 0
32 22 15 1
(39.0%) (17.1%) (20.3%) (6.7%) 1 0 0 0 0 0
<0.001
0.002
Responses with n < 10 are grouped together.
the majority in this group (43.3%, n ¼ 13) selected types of cases as most important.
important determining factor (p ¼ 0.047, AC vs GT). As such, mentorship influenced the decision making primarily in favor of GT (39.0%, n ¼ 32), and types of cases influenced the decision in favor of AC (46.5%, n ¼ 60). No significant predictors were identified for CC; however,
Comment
Fig 1. Difference in primary interest by level of training.
Although factors affecting interest in CTS as a whole specialty have been studied in the past [10], this study represents the first attempt to address the decision in career choice between specific fields of CTS. Our results demonstrated a difference in distribution of interests in AC/CC versus GT based on the trainee’s level of medical education. Trainees interested in AC or CC were most likely to make their career choice before or during medical school, whereas trainees interested in GT were more likely to make their career choice during GS training. More than half of the responders decided about their career choice during GS residency, emphasizing the importance of maintaining the traditional pathway. All four training pathways (2Y, 3Y, 4þ3, I-6) had a considerable proportion of individuals interested in AC. Nonetheless, those in I-6 and 4þ3 programs clearly had the greatest preference for AC (I-6 52.9%, 4þ3 46.7%). By contrast, individuals interested in GT were more attracted to the traditional training model, especially 2Y programs. This trend was also noted in another study by the TSRA that compared various aspects of 2Y versus 3Y training programs and found, although it was not statistically significant, that 3Y training programs had more cardiac-
GENERAL THORACIC
Decision time General surgery year 5 (n ¼ 8) General surgery years 3–4 (n ¼ (103) General surgery years 1–2 (n ¼ 44) During medical school (n ¼ 78) Before medical school (n ¼ 67) Training pathway 2-year standard (n ¼ 132) 3-year standard (n ¼ 102) 4þ3 standard (n ¼ 15) 6-year integrated (n ¼ 51) Primary motivating factor Mentorship (n ¼ 82) Types of cases (n ¼ 129) Personal experience (n ¼ 74) Other (n ¼ 15)a Critical care exposure (9) Challenging (2) Anatomy (1) Cardipulmonary physiology (1) Length of training (1) Little bit of all of the above (1)
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GENERAL THORACIC
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Fig 2. Difference in primary interest by training program type.
oriented and 2Y programs more thoracic-oriented individuals [11]. Even though it was a categoric variable, program type could be ordered based on time balance between general surgery and cardiac surgery. In this case, it would follow that cardiac-oriented individuals may be attracted to doing as little general surgery and as much cardiac surgery as possible (I-6 programs). By contrast, more general surgery and less cardiac surgery (2Y programs) may appeal to GT-oriented individuals. These differences in
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pathway type affect GT more significantly than AC/CC because there is a sizable proportion of cardiac-oriented individuals in every pathway. It should be noted that, traditionally, most I-6 and 4þ3 programs have been cardiac-oriented programs, which could create a selection bias. Alternatively, as suggested previously [1], GT-oriented individuals may be selfselecting out of I-6 programs in favor of a more robust general surgery experience. This may in particular apply to operations on the foregut where completing full general surgery residency may provide the trainee with a better skillset. Because I-6 programs are new, it may be too early to tell, and this may be how the early I-6 process is evolving. Still, our findings show the importance of traditional pathways [12] in producing graduates who will in fact practice GT. The primary motivating factor for career choice should by definition be considered a predictor. Interestingly however, the post-hoc analysis showed that only a fraction of these factors was actually predictive. Specifically, mentorship was the primary influencing factor for thoracic-oriented individuals, whereas types of cases held the most influence for cardiac-oriented individuals. One explanation is that the further along an individual is in training, the more likely the trainee is to be exposed to CTS mentors. It follows that individuals who have not even entered medical school are less likely to have exposure to CTS mentors. This is an important issue because even a brief involvement of a surgeon can influence the career choices of this population [13]—an effect that can be equally extrapolated to both AC/CC and GT. Also, most GS residency programs still have GT rotations but fewer AC rotations that may translate into selectively higher exposure to GT. Of note, Vaporciyan and colleagues [10] previously showed that with increasing length of the CTS rotation, the GS residents were more likely to commit to CTS and to agree that CTS faculty acted as role models and took an interest in their careers. However, no specific comparisons were made to delineate the differences between AC and GT. It has to be mentioned that whatever the current difference in exposure between AC and GT, it may change as the requirement for GT is dropped from general surgery. Although no specific factor was identified for congenital cardiac surgery, this is likely due to the small total number of individuals interested in the field and therefore does not reach statistical significance. Overall, the CC subset statistically behaved more like the AC than the GT subset. Statistically speaking, the MCT group does not appear to have differing characteristics. It is rather an “average” of the features of the cardiac-oriented and thoracicoriented groups, as demonstrated in Figures 1 through 3.
Limitations
Fig 3. Difference in primary interest by factors contributing to the decision. (AC ¼ adult cardiac; CC ¼ congenital cardiac; GT ¼ general thoracic; MCT ¼ mixed cardiac and thoracic.)
Career choice is a complex decision process and involves many possible factors (eg, age, gender, ethnicity, parental influence, USMLE scores) that were neither included in nor detected by the TSRA survey and our study. For example, the survey did not contain information on
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responders’ age and gender, which was previously shown to be an influence on overall career choice [14]. The survey was not devised with the goal to address the question of career choice. The results only provide a “snapshot” with no longitudinal analysis. Overall, although this study shows the current landscape (“what is happening”), it does not address the causality (“why it is happening”). Still, our results clearly show an important trend. Why this is so will be subject to future TSRA studies.
Conclusions
References 1. Tchantchaleishvili V, Hicks GL. Should integrated residency programs supplant traditional programs in cardiothoracic surgery? J Thorac Cardiovasc Surg 2014;148:379–80. 2. 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. 3. Lebastchi AH, Yuh DD. Nationwide survey of US integrated 6-year cardiothoracic surgical residents. J Thorac Cardiovasc Surg 2014;148:401–7.
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4. Tchantchaleishvili V, Lapar D, Stephens E, Odell D, DeNino W. Current integrated cardiothoracic surgery residents: a thoracic surgery residents association survey. Ann Thorac Surg 2015;99:1040–7. 5. Lee R. Help wanted. Ann Thorac Surg 2003;76:1779–81. 6. Stephens EH, Odell D, Stein W, et al. A decade of change: training and career paths of cardiothoracic surgery residents 2003 to 2014. Ann Thorac Surg 2015;100:1305–14. 7. Salazar JD, Lee R, Wheatley GH III, Doty JR. Are there enough jobs in cardiothoracic surgery? The Thoracic Surgery Residents Association job placement survey for finishing residents. Ann Thorac Surg 2004;78:1523–7. 8. Cooke DT, Kerendi F, Mettler BA, et al. Update on cardiothoracic surgery resident job opportunities. Ann Thorac Surg 2010;89:1853–9. 9. Akaike H. A new look at the statistical model identification. IEEE Trans Autom Control 1974;19:716–23. 10. 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. 11. Nguyen TC, Terwelp MD, Stephens EH, et al. Resident perceptions of 2 vs. 3-year cardiothoracic training programs. Ann Thorac Surg 2015;99:2070–6. 12. Sainathan S. Integrated thoracic residency: the only pathway of thoracic surgery training in the future? Ann Thorac Surg 2012;94:1374. 13. Kozar RA, Lucci A, Miller CC, et al. Brief intervention by surgeons can influence students toward a career in surgery. J Surg Res 2003;111:166–9. 14. Sanfey HA, Saalwachter-Schulman AR, Nyhof-Young JM, Eidelson B, Mann BD. Influences on medical student career choice: gender or generation? Arch Surg 2006;141:1086–94; discussion 1094.
DISCUSSION DR THOMAS WATSON (Rochester, NY): V.T., great job. The data are enlightening and support what a lot of us general thoracic surgeons fear: that the move from a traditional pathway to an integrated training paradigm will dry up the supply of well-trained thoracic surgeons. You suggest that we need to keep the traditional pathways open, but, unfortunately, that is a financial challenge for a lot of institutions. For instance, we have had to close our traditional paradigm because we have gone to funding the integrated program. So that may not be the right answer. Why do you think it is that medical students are interested in cardiac surgery and not thoracic surgery, and what can we do to get medical students more interested in thoracic surgery as another solution to this potential workforce issue? DR TCHANTCHALEISHVILI: This is a difficult question to answer. To me, general thoracic surgery is an intellectual specialty. It takes more exposure and experience, often found during general surgery residency, to fully appreciate its extent and magnitude. Cardiac surgery has a definite allure and seems to speak to people at an early stage of training. It is not unusual for these individuals to start dreaming of becoming cardiac surgeons before starting medical school. However with experience, it is foreseeable that a proportion of integrated residents will elect careers in general thoracic surgery. DR ARA A. VAPORCIYAN (Houston, TX): For us, we draw the largest group from those who wanted to be a surgical oncologist,
and then midway through general surgery they decide that thoracic gives them the surgical oncology, but also different procedures are enticing. I think that is where we see a large group of them. After they have rotated a few times on surgical oncology and like it, then suddenly they transition over. I agree with you that it is going to get difficult. If you are funding six full-time equivalents, they are going to be hard-pressed to give you two more full-time equivalents to maintain a traditional pathway. DR SAMUEL WEINSTEIN (New York, NY): I want to congratulate you on an excellent and interesting presentation. I have two questions. We have noticed the same trend that you described: that with our traditional pathway, the independent program, we have twice as many applicants now as we had 2 years ago, and roughly half of them are interested or declare themselves in noncardiac chest surgery. While you said that you didn’t have causality in your data, could you postulate why you think that is? Two, as I start to debate with my colleagues our decision to proceed or not to proceed with an integrated program, based on what you have seen, should we proceed or stick with what we have? DR TCHANTCHALEISHVILI: The survey was not devised to answer this question. The analysis only determines an association. We cannot say that one or the other factor is the cause of what is happening. Regarding your second question, I think it is important to keep all four pathways and not to restrict ourselves
GENERAL THORACIC
The findings of our study clearly outline interesting points that career choice in CTS appears strongly associated with level of training, exposure to mentors, and training paradigm. This bears significant implications on maintaining all training pathways open. Further studies are necessary to validate the findings.
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to a single one. This will provide diversity in the spectrum of training open to those in medical school and residency.
GENERAL THORACIC
DR MEGHANA HELDER (Rochester, MN): Traditional track fellows seem to be choosing general thoracic surgery over cardiac surgery. Also, general surgery residency programs have moved away from any time in cardiac surgery for their residents. Are there any questions in the survey that talk about experience in residency programs, as far as months of cardiac surgery or months of thoracic surgery, that you could draw from for causality there? DR TCHANTCHALEISHVILI: No, we did not have this information for analysis. However, it is well known that general surgery residents routinely rotate on general thoracic surgery services, but only a small fraction of them rotate on cardiac surgery. DR ANTHONY W. KIM (New Haven, CT): Your presentation was excellent. Did your survey instrument give you a chance to get a sense of any sort of crossover from one subspecialty to another? The reason I ask this question is because I noticed that you had four categories but did not include an undecided or undeclared group. DR TCHANTCHALEISHVILI: No, the survey questionnaire did not include this information. DR PAUL H. SCHIPPER (Portland, OR): I’m curious how mentorship rose to the top in driving the decision for general thoracic. How was that question asked in the survey? Was this
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a write-in thing? Were there other possibilities that they could also have chosen from that were not driving factors in this decision? DR TCHANTCHALEISHVILI: The question in the survey was “What was the most important factor that influenced the decision?” and one of the choices was mentorship. Just to emphasize, it was mentorship at the time of the decision, not at the time of our survey. Of note, in the survey there was another question: “Do you have a mentor? yes or no.” This question addressed having a mentor at the time of the survey, but the question was eliminated as a statistically insignificant predictor because both cardiac and thoracic trainees were mentored equally. What we think is happening is that medical students or individuals before medical school, who decide to be cardiac surgeons, do so without having a cardiac surgeon mentoring them. On the other hand, general surgery residents who have exposure to thoracic surgeons are mentored and encouraged to pursue that specialty. DR SCHIPPER: What were the other choices that mentorship may have beaten out? DR TCHANTCHALEISHVILI: Other choices besides mentorship included types of cases, personal experience, and an “other” option where respondents could enter free text. The individuals who chose the “other” free text option represented a smaller group. Free text answers included intensive care unit experience, cardiovascular physiology, and length of training, among others. These answers were grouped together for statistical analysis. The post-hoc analysis showed only mentorship and types of cases as being significant.