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The Thoracic Surgery Directors Association(TSDA): Focus upon Curriculum for Resident Education
The Thoracic Surgery Directors Association (TSDA): Focus upon Curriculum for Resident Education Mark B. Orringer Key words: Graduate education in surgery, curriculum implementation, funding, resident match, general surgery training, needs of practicing surgeons.
Background
T
horacic surgery residency has long presented the challenge of balancing the requirements of quality graduate medical education against often staggering, labor-intensive service needs. Historically, surgery (and its specialties) has been taught under an apprentice model of education, ie, "observe the master, do as I do until one day you, too, will be ready to be an independent surgeon." In reality, elementary school teachers who are, by training, educators have been far more organized about providing a structured curriculum for their pupils, defining what it is that they want to teach, how they are going to teach it, and how they are going to assess that the information has been learned by their students. The majority of thoracic surgery faculty members are not, by training, educators, and they have been unaccustomed to thinking about the most fundamental feature of the process of education: a curriculum. When historians review developments in the specialty of thoracic surgery, the decade of the 1990s will be recognized as a time of new commitment and energy on behalf of thoracic surgery resident education. In 1991, The Annals qfTlzoracic Surgery' published an editorial symposium on Thoracic Surgery Education. 1 The same year, Dr John Waldhausen, President of the AATS, convened a retreat of thoracic surgery leadership in Snow Bird, lIT, to address expressed concerns about the direction thoracic surgery education was taking-including educational endeavors. Recommendations arising out of the Snow Bird conference were to: (1) maintain the integrity of cardiothoracic surgery by providing integrated train-
From the Thoracic Surgery Directors Association, and the Section qf Thoracic Surgery. University qfMichigan Medical Center. Ann Arbor. J1I. Address reprint requests to Mark B. OrTinger, MD. Universit), qf Michigan Medical Center, 1500 E Medical Center Drive, 21:30 Taubman Center. Box 0344. Ann Arbor. MI 48109. Cop'yright © 1998 b)' WB. Saunders Company' 1043-0679/98/1003-0003$08.00/0
ing in both general thoracic and cardiac surgery; (2) improve the educational environment of thoracic surgery residents by reducing the service load and emphasizing the educational nature of residency; (3) establish a core curriculum for thoracic surgery; (4) permit residents to obtain specialized training within the field of thoracic surgery if they so desire (eg, in congenital heart disease, general thoracic surgery, heart or lung transplantation) ; (5) examine the need to retain American Board of Surgery certification; and (6) attempt to better integrate once again general and thoracic surgery resident education. 2 In October 1992, Dr Benson Wilcox, chairman of the STS Ad Hoc Committee on Graduate Education in Thoracic Surgery, organized aJoint Conference on Graduate Education in Thoracic Surgery in Oak Brook, IL, under sponsorship of the AATS, ABTS, the Coordinating Committee for Continuing Education in Thoracic Surgery (CCCETS), the STS, and the TSDA. This was a consensus conference that focused entirely upon thoracic surgery resident education and began to identify essential needs and deficiencies within our current system of resident education. In a subsequent report on the Oak Brook conference, Wilcox and Stritter3 emphasized the five critical components of creating a curriculum:
1. Expectations: defining what it is we want our students to know, e.g., the requirements for certification by the ABTS. 2. Construction of measures of performance: eg, in-training examinations, certification by the American Board of Surgery and the American Board of Thoracic Surgery. 3. Establishment of prerequisites: ensuring that students bring to the learning experience basic knowledge and skills required to complete the program successfully. 4. Design of the program: determining the content of the curriculum, the experiences or assignments the students will have, the teachers and instruc-
Seminars in Thoracic and Cardiovascular Surgery, Vol 10, No 3 (july). 1998: pp 173-177
173
174
Mark B . Orrillger
tional format for the course, and the time needed to complete the course. 5. Evaluation of the program: determining how effective the program is in mee ting its expectations. They urged that those responsible for teaching the curriculum in thoracic surgery re-evaluate the expectations so that "wha t w e want our residents to be, and to be able to do when they complete our programs" is clearly understood and so that we focus upon curriculum content redesign in order to produce "thoughtful, reflective, well-educated professionals." The Snow Bird and Oak Brook conferences were major catalysts in stimulating thoracic surgery leadership to focus more upon the content and quality of our residency education than simply upon the debate over "years of training. " The responsibility for teaching thoracic surgery rests largely upon the shoulders of the thoracic surgery program directors, the stewards of resident education. The ABTS certifies that individuals have successfully completed an approved educational program and have been evaluated with an examination designed t o assess the knowledge, experience, and skills required to provide highquality thoracic surgery care. The Residency Review Committee for Thoracic Surgery accredits programs tha t provide the resident the appropria tely defined educational experience to be proficient thoracic surgeons. But it is the directors o f the 90 U.S. thoracic surgery residency programs who have the responsibility for teaching the discipline and ensuring an appropriate environment for learning, and the TSDA is relatively young. It had its beginning in 1970, when several thoracic surgery program directors met for the first time at the annual mee ting of The Society of Thoracic Surgeons to air their concern that thoracic surgery training was being molded, directed, and dictated b yforces external to the directors, who had the immediate responsibility for r esidency training. In 1971, the Board of Thoracic Surgery severed its affiliation with the American B oard of Surgery and became a separate primary board, changing its name to the American Board of Thoracic Surgery. And in 1978, the Board voted that only candidates completing training in approved residency programs would be eligible for the certifying examina tion. During the same year, the Thoracic Surgery Directors Association (TSDA) was formally o rganized and incorporated. The objectives of the TSDA emphasized its mandate to improve thoracic surgery resident educa-
tion and to facilitate the solution of da ministrative problems arising in the conduct of thoracic surgery training programs. However, as extraordinary technical achievements in myocardial r evascularization occurred and coronary artery bypass dominated our specialty, there was tremendous imbalance between resident service and education in thoracic surgery. Only during the current decade has the TSDA begun to assume a more appropria te role in ensuring quality thoracic surgical education. The stimulus of thoracic surgical leadership's concern about the direction of our educational process as expressed at the Snow Bird and Oak Brook confere nces r esulted in a renewed commitment to thoracic surgery residents on t he part of the TSDA. In 1992, the TSDA established a uniform National Thoracic Surgery Residency Matching Program for residency selection in order to provide its general surgery resident applicants a consistent, orderly, and more fair selection process. Participation in the Matching Program became a prerequisite for membership in the TSDA. This sentinel event demonstra ted the ability of thoracic surgery program directors to work together on behalf of our residents and set the stage for a number of t he current cooperative efforts underway to enhance resident education. As an acknowledgment of the growing influence which the TSDA was expected to have in resident education, the American Board of Thoracic Surgery, at its April 1992 meeting, voted to change its organizational fram ework to include two representatives from the TSDA. At present, the TSDA consists of the 90 U.S. thoracic surgery residency program directors and up to one Associate Member from each program as d esignated by the Director. Canadian thoracic surgery program directors have Associate Member status. The TSDA meets twice each year, the Saturday before t he tsart of the STS and AATS annual meetings. T opics relevant to thoracic surgery education and administrative aspects of running a residency program arediscussed.
Evolution of a More Structured Curriculum In 1993, the Thoracic Surgery Directors Association undertook its Comprehensive Thoracic Surgery Curriculum project, which was a n fefort to reach a general consensus regarding the scope of study that should be encompassed in thoracic s urgery residency. This proj ect was endorsed b y t heAmerican Board of
TSDA Focus on Improving Resident Education
Thoracic Surgery, the Residency Review Committee for Thoracic Surgery, the AATS, and the STS. With input from a variety of program directors and thoracic surgery faculty, a curriculum outline was developed under the editorship of Stanton P. Nolan, MD, and Robert K Salley, MD. The TSDA Comprehensive Thoracic Surgery Curriculum was published in 1994.4 It was intended as a guide for study and clinical activities appropriate during thoracic surgery residency and as an aid to program directors in defining the scope of their programs. The Comprehensive Curriculum, encompassing the entire specialty of thoracic surgery, is divided into 14 study units, each consisting of four parts: Unit objective, which provides the rationale for the unit; underlying Learner Objectives, which define the knowledge to be acquired by the resident; Contents, which outline the study needed to achieve the objectives of the unit; and Clinical Skills, which describe the clinical activities and technical tasks deemed necessary for the resident to become an independent and safe thoracic surgeon. Within the Comprehensive Curriculum, the Learner Objectives and Clinical Skills determined by the authors of this project to be "essential" (ie, the minimum necessary requirements) are highlighted. The Comprehensive Thoracic Surgery Curriculum represents the first attempt to define the basic educational goals that should be met by every thoracic surgery residency program. This printed curriculum has been distributed to each program director and his or her faculty, and is currently serving as a guide for structuring lectures and conferences. It is recognized that the Comprehensive Curriculum is a dynamic document that will have to be reviewed and updated at 3- to 5-year intervals. No sooner had the Comprehensive Curriculum been completed than the TSDA recognized that having a printed outline was only the first step in improving the educational process for our residents. Implementation of the Curriculum has become the obvious next step and is a considerably more complicated task. A retreat of the thoracic surgery program directors was held September 6-7, 1996, in Chicago. At this TSDA retreat, six work groups discussed the following topics and brought recommendations to the plenary session for discussion by all the participants: (1) funding of the thoracic surgery residency, (2) the prerequisite curriculum, (3) thoracic surgerygeneral surgery relations, (4) thoracic surgery subspecialtyeducation ("tracking"), (5) American Board of Surgery certification, and (6) the future of the TSDA
175
in thoracic surgery education. A variety of recommendations evolved in each of these areas. 5 There was acknowledgment of the fact that thoracic surgery faculty must try harder to serve as role models and mentors who recognize their residents as individuals with personal needs. Other recommendations most directly pertaining to TSDA involvement in thoracic surgery education included (1) greater emphasis on curriculum implementation and (2) more resident participation and interaction with the TSDA. To achieve curriculum implementation, the newly revised TSDA bylaws have established three new standing committees: (1) the Requisite Curriculum Committee, which will be responsible for updating the Thoracic Surgery Comprehensive Curriculum at no less than 3-year intervals; (2) the Curriculum Implementation Committee, which will be responsible for developing the optimal methodology whereby the Comprehensive Curriculum is taught to thoracic surgical residents; and (3) the Prerequisite Curriculum Committee, which will be responsible for defining, developing, and implementing, where appropriate (a) the general surgical curriculum (core knowledge) and (b) the thoracic surgery curriculum (core knowledge) deemed essential for residents beginning their thoracic surgical education. Each of these committees is now involved with meeting its charge. The ambitious agendas of these committees have been established by Irving Kron, MD, Chairman of the Curriculum Implementation Committee. Rapidly evolving advances in medical information technology have provided a foundation for developing exciting interactive electronic formats for the transmission of information to our residents. Rather than the standard textbook chapter on a topic in thoracic surgery, our residents will ultimately be able to access on their computers text that is hyper-linked to appropriate reference articles, video clips showing operative technique, cardiac catheterization data, endoscopy findings, etc. Topics that are not wellcovered by the majority of thoracic surgery residency programs (eg, fungal diseases of the chest, esophageal motility studies, ventilator management) may be developed using TSDA standardized interactive formats to provide at least minimal basic knowledge to all of our residents, thereby increasing the overall quality of thoracic surgery knowledge in this country. A residents' video library is being defined so that program directors can provide reference videos of operations to their thoracic surgery residents. Curtis Tribble, MD, of the University of Virginia thoracic
176
Mark B. Orringer
surgery faculty, recently organized for the Thoracic Surgery Directors Association a course entitled "Thoracic Surgeons as Educators: Lessons from Other Elite Performers." Its faculty consisted of experts in assessing and motivating other high performers, eg, Olympic athletes and business executives. A greater awareness and understanding of such mentorship skills by thoracic surgery faculty will be essential for the success of the TSDA curriculum implementation efforts. David Fullerton, MD, and Debra DeRosa, PhD, have just completed the first organized assessment of the relevance of thoracic surgery residency education to clinical practice. This effort involved a survey of all thoracic surgeons who have completed residency within the past 5 years. The report is now being compiled and will represent an initial effort on the part of the TSDA to link our educational efforts with the needs of practicing thoracic surgeons. The Prerequisite Curriculum Committee of the TSDA has set about to use innovative medical information technology to provide general surgery residents accepted into thoracic surgery residency programs a standardized prerequisite thoracic surgery curriculum that will ensure a better fundamental knowledge base for all of our residents. It is envisioned, for example, that upon acceptance into thoracic surgery residency I year before completion of general surgery residency, each resident will receive a set of TSDA Prerequisite Curriculum CD-ROM disks that will cover 10 basic thoracic surgery clinical scenarios (eg, coronary artery disease, aortic stenosis, esophageal stricture, lung cancer, tetralogy of Fallot, PDA) and provide basic knowledge in pathophysiology, diagnostic assessment, operative technique, and postoperative care. A self-assessment examination at the conclusion of each unit would demonstrate to both the resident and the future program director that that individual has completed the unit and mastered the information within it. These exciting innovations in education technology can only enhance the final product of our residency programs.
Future Challenges for the TSDA Curriculum Efforts The futuristic educational efforts described above will require time and commitment from many thoracic surgery residency program directors and their faculty. The effort will be analogous to the prepara-
tion of multiple book chapters, but our new-age book chapters will require integration of multiple media including radiographs, CT scans, cardiac catheterizations, electrocardiograms, videos demonstrating operative technique, etc. Substantial administrative organization and financial support will be required to complete this project. The specialty of thoracic surgery clearly has an obligation to support improvements in resident education from which we will all benefit professionally. The TSDA will turn to our national thoracic surgery organizations and to corporate sponsors for financial support of our curriculum implementation activities. Perhaps the greatest challenge to these efforts to improve thoracic surgery resident education is the pressures of the current health care environment, which does not reward the teacher! Despite the focus of managed care on increasing clinical volume and throughput, for our specialty to survive, our residents must be properly educated, and the "surgeons as educators" (mentorship) philosophy must be insinuated into our residency programs and become ingrained within our faculty. The Thoracic Surgery Directors Association has encouraged the establishment of a Thoracic Surgery Residents Association (TSRA), a national organization consisting of all thoracic surgery residents, which will serve as an interface between the residents and directors (students and teachers), thereby giving the residents the opportunity to influence the curriculum and to be better informed on national issues affecting thoracic surgery residency. Last but not least is the need that has been articulated by Benson Wilcox, MD, to define a responsible system for prerequisite surgical education. If all surgical disciplines could agree upon a basic surgical core curriculum that every residentregardless of his or her ultimate specialty-should master, subsequent years could then be devoted to specialty training, perhaps without the need for ABTS certification, and possibly allowing completion of thoracic surgery residency in a shorter period of time than is now possible. In summary, the TSDA is strongly committed to improvements in the overall educational experience of our residents. This will require a deliberate and concerted effort on the part of the directors and their faculty to accept the responsibilities of being true mentors and "protectors" of the residents during this educational experience. Although this is stretching the point a bit, the term "residency training pro-
TSDA Focus on Improving Resident Education
gram" should be socially unacceptable, or at least cause us all to think twice. As Dr Ward Griffin, past secretary of the American Board of Surgery, reminded us, ''You train dogs and horses. You educate residents." Improvements in medical information technology alone will not assure better residency education unless the residents are given adequate release time from clinical responsibilities to use it and study. It is important that we remind ourselves that the residency years of postgraduate medical education are comparable to the years when postgraduate students in other disciplines obtain their PhD degrees. The balance between service and education in thoracic surgery residency education is precarious. There is clearly a resolve among the
177
Program Directors to pay more attention to this balance.
References 1. Peters RM, Grillo HC, KirklinJW, et al: Editorial symposium on thoracic surgery education. Ann Thorac Surg 51:807-820, 1991 2. WaldhausenJA: The Association at seventy-five: The challenge of the future (Presidential Address). J Thorac Cardiovasc Surg 104:1183-1194,1992 3. Wilcox BR, Stritter IT: Curriculum change for graduate education in thoracic surgery. Ann Thorac Surg 55:1332-1336, 1993 4. TSDA Comprehensive Surgery Curriculum: Arlington, VA, Thoracic Surgery Directors Association, 1994 5. Benfield JR: Thoracic Surgery Directors Association report 1995-1997. Ann Thorac Surg64:1212-1215, 1997
Background
T
horacic surgery residency has long presented the challenge of balancing the requirements of quality graduate medical education against often staggering, labor-intensive service needs. Historically, surgery (and its specialties) has been taught under an apprentice model of education, ie, "observe the master, do as I do until one day you, too, will be ready to be an independent surgeon." In reality, elementary school teachers who are, by training, educators have been far more organized about providing a structured curriculum for their pupils, defining what it is that they want to teach, how they are going to teach it, and how they are going to assess that the information has been learned by their students. The majority of thoracic surgery faculty members are not, by training, educators, and they have been unaccustomed to thinking about the most fundamental feature of the process of education: a curriculum. When historians review developments in the specialty of thoracic surgery, the decade of the 1990s will be recognized as a time of new commitment and energy on behalf of thoracic surgery resident education. In 1991, The Annals qfTlzoracic Surgery' published an editorial symposium on Thoracic Surgery Education. 1 The same year, Dr John Waldhausen, President of the AATS, convened a retreat of thoracic surgery leadership in Snow Bird, lIT, to address expressed concerns about the direction thoracic surgery education was taking-including educational endeavors. Recommendations arising out of the Snow Bird conference were to: (1) maintain the integrity of cardiothoracic surgery by providing integrated train-
From the Thoracic Surgery Directors Association, and the Section qf Thoracic Surgery. University qfMichigan Medical Center. Ann Arbor. J1I. Address reprint requests to Mark B. OrTinger, MD. Universit), qf Michigan Medical Center, 1500 E Medical Center Drive, 21:30 Taubman Center. Box 0344. Ann Arbor. MI 48109. Cop'yright © 1998 b)' WB. Saunders Company' 1043-0679/98/1003-0003$08.00/0
ing in both general thoracic and cardiac surgery; (2) improve the educational environment of thoracic surgery residents by reducing the service load and emphasizing the educational nature of residency; (3) establish a core curriculum for thoracic surgery; (4) permit residents to obtain specialized training within the field of thoracic surgery if they so desire (eg, in congenital heart disease, general thoracic surgery, heart or lung transplantation) ; (5) examine the need to retain American Board of Surgery certification; and (6) attempt to better integrate once again general and thoracic surgery resident education. 2 In October 1992, Dr Benson Wilcox, chairman of the STS Ad Hoc Committee on Graduate Education in Thoracic Surgery, organized aJoint Conference on Graduate Education in Thoracic Surgery in Oak Brook, IL, under sponsorship of the AATS, ABTS, the Coordinating Committee for Continuing Education in Thoracic Surgery (CCCETS), the STS, and the TSDA. This was a consensus conference that focused entirely upon thoracic surgery resident education and began to identify essential needs and deficiencies within our current system of resident education. In a subsequent report on the Oak Brook conference, Wilcox and Stritter3 emphasized the five critical components of creating a curriculum:
1. Expectations: defining what it is we want our students to know, e.g., the requirements for certification by the ABTS. 2. Construction of measures of performance: eg, in-training examinations, certification by the American Board of Surgery and the American Board of Thoracic Surgery. 3. Establishment of prerequisites: ensuring that students bring to the learning experience basic knowledge and skills required to complete the program successfully. 4. Design of the program: determining the content of the curriculum, the experiences or assignments the students will have, the teachers and instruc-
Seminars in Thoracic and Cardiovascular Surgery, Vol 10, No 3 (july). 1998: pp 173-177
173
174
Mark B . Orrillger
tional format for the course, and the time needed to complete the course. 5. Evaluation of the program: determining how effective the program is in mee ting its expectations. They urged that those responsible for teaching the curriculum in thoracic surgery re-evaluate the expectations so that "wha t w e want our residents to be, and to be able to do when they complete our programs" is clearly understood and so that we focus upon curriculum content redesign in order to produce "thoughtful, reflective, well-educated professionals." The Snow Bird and Oak Brook conferences were major catalysts in stimulating thoracic surgery leadership to focus more upon the content and quality of our residency education than simply upon the debate over "years of training. " The responsibility for teaching thoracic surgery rests largely upon the shoulders of the thoracic surgery program directors, the stewards of resident education. The ABTS certifies that individuals have successfully completed an approved educational program and have been evaluated with an examination designed t o assess the knowledge, experience, and skills required to provide highquality thoracic surgery care. The Residency Review Committee for Thoracic Surgery accredits programs tha t provide the resident the appropria tely defined educational experience to be proficient thoracic surgeons. But it is the directors o f the 90 U.S. thoracic surgery residency programs who have the responsibility for teaching the discipline and ensuring an appropriate environment for learning, and the TSDA is relatively young. It had its beginning in 1970, when several thoracic surgery program directors met for the first time at the annual mee ting of The Society of Thoracic Surgeons to air their concern that thoracic surgery training was being molded, directed, and dictated b yforces external to the directors, who had the immediate responsibility for r esidency training. In 1971, the Board of Thoracic Surgery severed its affiliation with the American B oard of Surgery and became a separate primary board, changing its name to the American Board of Thoracic Surgery. And in 1978, the Board voted that only candidates completing training in approved residency programs would be eligible for the certifying examina tion. During the same year, the Thoracic Surgery Directors Association (TSDA) was formally o rganized and incorporated. The objectives of the TSDA emphasized its mandate to improve thoracic surgery resident educa-
tion and to facilitate the solution of da ministrative problems arising in the conduct of thoracic surgery training programs. However, as extraordinary technical achievements in myocardial r evascularization occurred and coronary artery bypass dominated our specialty, there was tremendous imbalance between resident service and education in thoracic surgery. Only during the current decade has the TSDA begun to assume a more appropria te role in ensuring quality thoracic surgical education. The stimulus of thoracic surgical leadership's concern about the direction of our educational process as expressed at the Snow Bird and Oak Brook confere nces r esulted in a renewed commitment to thoracic surgery residents on t he part of the TSDA. In 1992, the TSDA established a uniform National Thoracic Surgery Residency Matching Program for residency selection in order to provide its general surgery resident applicants a consistent, orderly, and more fair selection process. Participation in the Matching Program became a prerequisite for membership in the TSDA. This sentinel event demonstra ted the ability of thoracic surgery program directors to work together on behalf of our residents and set the stage for a number of t he current cooperative efforts underway to enhance resident education. As an acknowledgment of the growing influence which the TSDA was expected to have in resident education, the American Board of Thoracic Surgery, at its April 1992 meeting, voted to change its organizational fram ework to include two representatives from the TSDA. At present, the TSDA consists of the 90 U.S. thoracic surgery residency program directors and up to one Associate Member from each program as d esignated by the Director. Canadian thoracic surgery program directors have Associate Member status. The TSDA meets twice each year, the Saturday before t he tsart of the STS and AATS annual meetings. T opics relevant to thoracic surgery education and administrative aspects of running a residency program arediscussed.
Evolution of a More Structured Curriculum In 1993, the Thoracic Surgery Directors Association undertook its Comprehensive Thoracic Surgery Curriculum project, which was a n fefort to reach a general consensus regarding the scope of study that should be encompassed in thoracic s urgery residency. This proj ect was endorsed b y t heAmerican Board of
TSDA Focus on Improving Resident Education
Thoracic Surgery, the Residency Review Committee for Thoracic Surgery, the AATS, and the STS. With input from a variety of program directors and thoracic surgery faculty, a curriculum outline was developed under the editorship of Stanton P. Nolan, MD, and Robert K Salley, MD. The TSDA Comprehensive Thoracic Surgery Curriculum was published in 1994.4 It was intended as a guide for study and clinical activities appropriate during thoracic surgery residency and as an aid to program directors in defining the scope of their programs. The Comprehensive Curriculum, encompassing the entire specialty of thoracic surgery, is divided into 14 study units, each consisting of four parts: Unit objective, which provides the rationale for the unit; underlying Learner Objectives, which define the knowledge to be acquired by the resident; Contents, which outline the study needed to achieve the objectives of the unit; and Clinical Skills, which describe the clinical activities and technical tasks deemed necessary for the resident to become an independent and safe thoracic surgeon. Within the Comprehensive Curriculum, the Learner Objectives and Clinical Skills determined by the authors of this project to be "essential" (ie, the minimum necessary requirements) are highlighted. The Comprehensive Thoracic Surgery Curriculum represents the first attempt to define the basic educational goals that should be met by every thoracic surgery residency program. This printed curriculum has been distributed to each program director and his or her faculty, and is currently serving as a guide for structuring lectures and conferences. It is recognized that the Comprehensive Curriculum is a dynamic document that will have to be reviewed and updated at 3- to 5-year intervals. No sooner had the Comprehensive Curriculum been completed than the TSDA recognized that having a printed outline was only the first step in improving the educational process for our residents. Implementation of the Curriculum has become the obvious next step and is a considerably more complicated task. A retreat of the thoracic surgery program directors was held September 6-7, 1996, in Chicago. At this TSDA retreat, six work groups discussed the following topics and brought recommendations to the plenary session for discussion by all the participants: (1) funding of the thoracic surgery residency, (2) the prerequisite curriculum, (3) thoracic surgerygeneral surgery relations, (4) thoracic surgery subspecialtyeducation ("tracking"), (5) American Board of Surgery certification, and (6) the future of the TSDA
175
in thoracic surgery education. A variety of recommendations evolved in each of these areas. 5 There was acknowledgment of the fact that thoracic surgery faculty must try harder to serve as role models and mentors who recognize their residents as individuals with personal needs. Other recommendations most directly pertaining to TSDA involvement in thoracic surgery education included (1) greater emphasis on curriculum implementation and (2) more resident participation and interaction with the TSDA. To achieve curriculum implementation, the newly revised TSDA bylaws have established three new standing committees: (1) the Requisite Curriculum Committee, which will be responsible for updating the Thoracic Surgery Comprehensive Curriculum at no less than 3-year intervals; (2) the Curriculum Implementation Committee, which will be responsible for developing the optimal methodology whereby the Comprehensive Curriculum is taught to thoracic surgical residents; and (3) the Prerequisite Curriculum Committee, which will be responsible for defining, developing, and implementing, where appropriate (a) the general surgical curriculum (core knowledge) and (b) the thoracic surgery curriculum (core knowledge) deemed essential for residents beginning their thoracic surgical education. Each of these committees is now involved with meeting its charge. The ambitious agendas of these committees have been established by Irving Kron, MD, Chairman of the Curriculum Implementation Committee. Rapidly evolving advances in medical information technology have provided a foundation for developing exciting interactive electronic formats for the transmission of information to our residents. Rather than the standard textbook chapter on a topic in thoracic surgery, our residents will ultimately be able to access on their computers text that is hyper-linked to appropriate reference articles, video clips showing operative technique, cardiac catheterization data, endoscopy findings, etc. Topics that are not wellcovered by the majority of thoracic surgery residency programs (eg, fungal diseases of the chest, esophageal motility studies, ventilator management) may be developed using TSDA standardized interactive formats to provide at least minimal basic knowledge to all of our residents, thereby increasing the overall quality of thoracic surgery knowledge in this country. A residents' video library is being defined so that program directors can provide reference videos of operations to their thoracic surgery residents. Curtis Tribble, MD, of the University of Virginia thoracic
176
Mark B. Orringer
surgery faculty, recently organized for the Thoracic Surgery Directors Association a course entitled "Thoracic Surgeons as Educators: Lessons from Other Elite Performers." Its faculty consisted of experts in assessing and motivating other high performers, eg, Olympic athletes and business executives. A greater awareness and understanding of such mentorship skills by thoracic surgery faculty will be essential for the success of the TSDA curriculum implementation efforts. David Fullerton, MD, and Debra DeRosa, PhD, have just completed the first organized assessment of the relevance of thoracic surgery residency education to clinical practice. This effort involved a survey of all thoracic surgeons who have completed residency within the past 5 years. The report is now being compiled and will represent an initial effort on the part of the TSDA to link our educational efforts with the needs of practicing thoracic surgeons. The Prerequisite Curriculum Committee of the TSDA has set about to use innovative medical information technology to provide general surgery residents accepted into thoracic surgery residency programs a standardized prerequisite thoracic surgery curriculum that will ensure a better fundamental knowledge base for all of our residents. It is envisioned, for example, that upon acceptance into thoracic surgery residency I year before completion of general surgery residency, each resident will receive a set of TSDA Prerequisite Curriculum CD-ROM disks that will cover 10 basic thoracic surgery clinical scenarios (eg, coronary artery disease, aortic stenosis, esophageal stricture, lung cancer, tetralogy of Fallot, PDA) and provide basic knowledge in pathophysiology, diagnostic assessment, operative technique, and postoperative care. A self-assessment examination at the conclusion of each unit would demonstrate to both the resident and the future program director that that individual has completed the unit and mastered the information within it. These exciting innovations in education technology can only enhance the final product of our residency programs.
Future Challenges for the TSDA Curriculum Efforts The futuristic educational efforts described above will require time and commitment from many thoracic surgery residency program directors and their faculty. The effort will be analogous to the prepara-
tion of multiple book chapters, but our new-age book chapters will require integration of multiple media including radiographs, CT scans, cardiac catheterizations, electrocardiograms, videos demonstrating operative technique, etc. Substantial administrative organization and financial support will be required to complete this project. The specialty of thoracic surgery clearly has an obligation to support improvements in resident education from which we will all benefit professionally. The TSDA will turn to our national thoracic surgery organizations and to corporate sponsors for financial support of our curriculum implementation activities. Perhaps the greatest challenge to these efforts to improve thoracic surgery resident education is the pressures of the current health care environment, which does not reward the teacher! Despite the focus of managed care on increasing clinical volume and throughput, for our specialty to survive, our residents must be properly educated, and the "surgeons as educators" (mentorship) philosophy must be insinuated into our residency programs and become ingrained within our faculty. The Thoracic Surgery Directors Association has encouraged the establishment of a Thoracic Surgery Residents Association (TSRA), a national organization consisting of all thoracic surgery residents, which will serve as an interface between the residents and directors (students and teachers), thereby giving the residents the opportunity to influence the curriculum and to be better informed on national issues affecting thoracic surgery residency. Last but not least is the need that has been articulated by Benson Wilcox, MD, to define a responsible system for prerequisite surgical education. If all surgical disciplines could agree upon a basic surgical core curriculum that every residentregardless of his or her ultimate specialty-should master, subsequent years could then be devoted to specialty training, perhaps without the need for ABTS certification, and possibly allowing completion of thoracic surgery residency in a shorter period of time than is now possible. In summary, the TSDA is strongly committed to improvements in the overall educational experience of our residents. This will require a deliberate and concerted effort on the part of the directors and their faculty to accept the responsibilities of being true mentors and "protectors" of the residents during this educational experience. Although this is stretching the point a bit, the term "residency training pro-
TSDA Focus on Improving Resident Education
gram" should be socially unacceptable, or at least cause us all to think twice. As Dr Ward Griffin, past secretary of the American Board of Surgery, reminded us, ''You train dogs and horses. You educate residents." Improvements in medical information technology alone will not assure better residency education unless the residents are given adequate release time from clinical responsibilities to use it and study. It is important that we remind ourselves that the residency years of postgraduate medical education are comparable to the years when postgraduate students in other disciplines obtain their PhD degrees. The balance between service and education in thoracic surgery residency education is precarious. There is clearly a resolve among the
177
Program Directors to pay more attention to this balance.
References 1. Peters RM, Grillo HC, KirklinJW, et al: Editorial symposium on thoracic surgery education. Ann Thorac Surg 51:807-820, 1991 2. WaldhausenJA: The Association at seventy-five: The challenge of the future (Presidential Address). J Thorac Cardiovasc Surg 104:1183-1194,1992 3. Wilcox BR, Stritter IT: Curriculum change for graduate education in thoracic surgery. Ann Thorac Surg 55:1332-1336, 1993 4. TSDA Comprehensive Surgery Curriculum: Arlington, VA, Thoracic Surgery Directors Association, 1994 5. Benfield JR: Thoracic Surgery Directors Association report 1995-1997. Ann Thorac Surg64:1212-1215, 1997