Integrated Surgical Residency Initiative: Implications for Cardiothoracic Surgery

Author's Accepted Manuscript

Integrated Surgical Residency Initiative: Implicationsfor Cardiothoracic Surgery

John S. Ikonomidis MD, PhD, Fred A. Crawford Jr.MD, James I. Fann MD

PII: S1043-0679(14)00009-4DOI: http://dx.doi.org/10.1053/j.semtcvs.2014.02.003Reference: YSTCS679

To appear in: Semin Thoracic Surg

Cite this article as: John S. Ikonomidis MD, PhD, Fred A. Crawford Jr. MD, James I. FannMD, Integrated Surgical Residency Initiative: Implications for Cardiothoracic Surgery,Semin Thoracic Surg, http://dx.doi.org/10.1053/j.semtcvs.2014.02.003

This is a PDF file of an unedited manuscript that has been accepted for publication. As aservice to our customers we are providing this early version of the manuscript. Themanuscript will undergo copyediting, typesetting, and review of the resulting galley proofbefore it is published in its final citable form. Please note that during the production processerrors may be discovered which could affect the content, and all legal disclaimers that applyto the journal pertain.

www.elsevier.com/locate/buildenv

Integrated Surgical Residency Initiative: Implications for Cardiothoracic Surgery

John S. Ikonomidis MD, PhD,1 Fred A. Crawford, Jr. MD,1 James I. Fann MD2

From the 1Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC and the 2Department of Cardiovascular Surgery, Stanford University, Stanford, CA

Running Header: I-6 CT Surgical Residency Word Count: 4480 Number of tables: 1 Number of Figures: 4

Address for correspondence:

John S. Ikonomidis MD, PhD Division of Cardiothoracic Surgery Department of Surgery Medical University of South Carolina Suite 7030 25 Courtenay Drive Charleston, SC 29425 Email: [email protected] Telephone: (843) 876-4842 Facsimile: (843) 876-4866

I-6 CT Surgical Residency

2

History and Development

Formal thoracic surgery education began when John Alexander established the first thoracic surgery

residency at the University of Michigan in 1928. At that time, thoracic surgery consisted mostly of surgery for

tuberculosis and empyema. At the 1936 American Association for Thoracic Surgery meeting, Alexander

discussed thoracic surgery education and stated that in addition to general surgery training, “two years of

intensive study and practice… are sufficient to take the examination of a board.” He went on to say, however,

that “a greater length of time would be desirable.”1 With the passage of time, thoracic surgery expanded to

include all types of pulmonary and esophageal surgery, adult and pediatric cardiac surgery, heart and lung

transplantation, and ventricular assist devices—to mention just a few. Despite this much more comprehensive

specialty and knowledge base, thoracic surgery residency remained two years in duration. Recognizing that the

specialty had expanded, some residency programs lengthened their residency from two to three years in the

1980’s to meet the needs of the changing specialty.

As an aside, it should be noted that thoracic surgery education was not then and is not now uniform

throughout the world. Exposure to thoracic surgery ranges from 22 to 90 months in different countries and is

not even defined in many. For example, the European Association for Cardio-Thoracic Surgery is currently

developing a pan-European training curriculum which will make thoracic surgery education more standardized

among all European countries. Training exposure to general surgery is also highly variable.2

The American Board of Thoracic Surgery (ABTS) began as a subsidiary board of the American Board

of Surgery but became an independent board in 1971. By the late 80’s and early 90’s, virtually every ABTS

meeting included formal and informal discussions regarding changes needed to improve thoracic surgery

education. Numerous presidential addresses to the AATS, Society of Thoracic Surgeons (STS) and Thoracic

Surgery Directors Association (TSDA) were devoted to this same topic.3 Two major stand-alone meetings,

Snowbird (1991) and Oakbrook (1992), were devoted to thoracic surgery education and changes were


3

advocated. There was general agreement that time devoted to general surgery training should be decreased and

that time for cardiothoracic (CT) surgery should be increased.

Numerous discussions were held with ABS leadership to explore ways to increase exposure to thoracic

surgery during general surgery residency while still allowing for ABS certification. These discussions were not

fruitful and in fact requirements for ABS certification became even more rigid. Another issue that frustrated

thoracic surgery program directors was that residents spent their first year of CT training concentrating on

studying to pass the ABS examination (which was a requirement for subsequent ABTS certification), leaving

little time to learn CT surgery.

A major hindrance to change was that many organizations (ABTS, TSDA, AATS, STS and Thoracic

Surgery Residency Review Committee (RRC)) within the specialty had significant influence on thoracic

surgery education and hence, obtaining unanimous agreement on change was essentially impossible. To

address this, the Joint Council on Thoracic Surgery Education (JCTSE) was first formed in 1996 and included

representation from each of these organizations. It quickly became clear that the major impediment to

substantive change was the requirement (by the ABTS) for ABS certification as a prerequisite for subsequent

ABTS certification. In 1999, members of the ABTS unanimously agreed that at some time in the future (after

input was obtained from all interested parties), ABS certification would become optional. The JCTSE

subsequently proposed a series of recommendations that were carefully considered, modified and approved by

the ABTS in October, 2001. The most important of these was that certification by the ABS would become

optional, rather than mandatory, for residents beginning thoracic surgery training in July, 2003 and after. This

decision opened the door for several possible pathways to ABTS certification, one of which was a categorical

six-year integrated CT surgery residency which would match directly out of medical school with a curriculum

to be developed by the TSDA. Before approving and implementing such programs, standards and requirements

would require approval from the Surgery RRC. Residents in this program (subsequently termed I-6) would be

under the direct supervision of the thoracic surgery program director for the entire six years, even though some


4

rotations would occur in other specialties (general surgery, vascular surgery, cardiology, etc.). It was estimated

that the first I-6 program would begin to accept residents by 2004 at the earliest. The first three programs

approved (Stanford, University of Pennsylvania, and Medical University of South Carolina) accepted their first

class in 2009. Although there had been much discussion about whether medical students would want to match

directly out of medical school, competition for these initial positions was intense and has continued even though

the number of approved programs has now increased to 25.

Pre-requisites and Logistics

A critical component to the success of the integrated six year program is engagement by all faculty

members. The I-6 CT Residency caters to a different population of trainees than the classical traditional

paradigm. Residents have completed medical school but have limited or no experience in patient care and

technical surgical skills. As a result, faculty surgeons must be prepared to spend more time than they may be

used to with residents and caring for their patients. In this training paradigm, the faculty has the opportunity to

develop the clinical skills of these residents from the beginning. Some will view this as a welcome challenge,

others, as a nuisance. This latter type of perception from faculty members must be vehemently discouraged.

During the application and interview period, I-6 residency applicants may develop misgivings about programs

where it is clear that certain faculty members are not enthusiastically engaged in the training paradigm, as a

result, such interactions will no doubt impact their ultimate ranking of those programs.

Program directors will need to decide, given their yearly resident number allotment, whether to abandon

the traditional training route and convert exclusively to the I-6 paradigm. Arguments for maintaining the

traditional paradigm include the opportunity for I-6 residents to work with more mature resident trainees who

have already completed a surgical residency. It is also interesting, from an academic point of view, to measure

the progress of the senior I-6 residents compared with the traditional residents regarding their in-training

examination scores, technical skills, case numbers, and overall patient management skills. Lastly, there is

concern regarding resident attrition in the first few years of the I-6 program just as there is in general surgery


5

programs. Because, the RRC currently does not permit a resident to transfer into the I-6 program past the

second year, maintaining the traditional training pathway allows a mechanism to recruit other residents to

maintain the required complement for that program should attrition occur. Interestingly, while attrition rates in

general surgery residencies approach 20%,4 there has been very little attrition in the I-6 paradigm thus far.

Currently, there is no set guideline for the rotation structure for the I-6 paradigm. Hence, program

directors have considerable freedom to designing rotation blocks. However, it must be born in mind that the

rotations assigned must conform to ABTS case requirements. A sample six year rotation block is provided in

Figure 1.

Part of the attraction to (and hopefully the success of) the I-6 program lies in its ability to provide

residents with an advanced, comprehensive breadth of training in the treatment of cardiovascular and thoracic

disease. This goal is accomplished by the inclusion of a variety of rotations that would ordinarily not be

obtained in the traditional paradigm such as advanced vascular surgery, interventional radiology and

cardiology, heart failure cardiology, pulmonary medicine, and advanced chest imaging. It behooves the

program directors of I-6 programs to have a cordial and collegial relationship with the directors of these various

programs in order to arrange resident rotations. Even after these rotations are established, careful scrutiny of

these rotations is necessary in order to ensure that the residents are getting an adequate experience. One

approach would be to require that residents provide a summary of each rotation on its completion and perhaps

even have a quarterly meeting with those residents to gauge the success of the various rotations. Good rotations

should be kept in the rotation block; inadequate rotations should be modified or dropped in favor of other more

valuable rotations.

The success of the program depends on close monitoring. Meetings with the residents at least every 6

months to review case requirements and adequacy of training are essential. Furhter, it is important to assign a

faculty mentor to each resident in order for the resident to have a contact person to discuss developmental

issues on a regular basis.


6

Case Requirements

A critical component to the I-6 CT paradigm is the achievement of a required number of operations. For

the first three years of training, 375 operations must be performed, of which 125 must be

cardiothoracic operations, up to 50 which may be component cases such as sternotomy and closure,

thoracotomy and closure, left internal mammary artery takedown, saphenous vein harvest, aortic and venous

cannulation, proximal and distal anastomosis, other vascular anastomosis and gastric/esophageal mobilization.

For years 4 to 6, a minimum of 125 major cardiothoracic operations must be performed each year, for a

minimum of 375 major cases in total. Also, residents must perform 150 indexed ABS cases over the six years

of training. These case requirements can be onerous (particularly in the first three years) and therefore,

considerable thought must be put into the rotation configuration. Because these case requirements were

introduced over a period of years, some programs that were early in adopting the I-6 paradigm needed to

modify their block diagrams as changes occurred in order to comfortably provide the requisite case numbers,

particularly relating to general surgery. Often programs may find it difficult obtain the required general surgical

cases if the resident were limited to general surgery rotations at their academic institution. This occurs because

there is a significant hierarchy within general surgery residencies such that most categorical residents do not

receive significant surgical experience until their third year of training. In addition, general surgery program

directors may be reluctant to allow I-6 CT residents the opportunity to jump the hierarchy and do cases that

normally their general surgery residents would not perform until their senior years. In order to gauge whether or

not a general surgery residency program would offer sufficient volume and breadth to support an I-6 CT

residency program, ask the general surgery program director to review the case logs of a cohort of their most

recent residents over their first three years of training to assess whether or not they would satisfy the I-6 CT

ABS case requirements. Subjecting residents to three years as a categorical general surgery resident to obtain


7

the ABS requirement would not only be untenable due to the 125 CT case requirement, but also defeats one of

the primary objectives of the I-6 paradigm, which is to broaden the scope of cardiothoracic surgical training.

Thus, in some cases serious consideration should be given to an affiliation with an outside general surgical

group where residents may acquire a large volume of cases in a relatively short period of time.

Didactic Education

Because CT surgery training historically required completion of general surgery residency, the I-6

approach mandates that its educators assume ownership of basic as well as advanced skills training and the

formation of a robust educational infrastructure that includes didactic education and standardized

assessments.5,6 Current efforts in CT surgery education have centered on restructuring existing models and

developing novel tools such online instruction and simulation-based learning. Conducted by the JCTSE in

2012, a survey of 50 residents in integrated residency programs indicated that the overall experience has been

positive for most residents.5 However, perceived deficiencies included a marginal operative experience on

general surgery rotations, lack of clarity of the value of “component’ operations (R-1 performs sternotomy, R-2

cannulates the aorta, R-3 does proximal anastomosis, etc.), variable value of non-surgical rotations, low volume

of operations in first 3 years, and need for a defined integrated curriculum.5 Going forward, resources have been

directed to address these concerns in the integrated paradigm, one of which is to ensure that all residents be

exposed to a standard curriculum.

It has been proposed that the use of a textbook model of content delivery is outdated; content should be

readily accessible, easy to update and adaptable to different learning styles.5 Through combined efforts of the

JCTSE, ABTS, TSDA and Thoracic Surgery Resident Association (TSRA), educators have constructed an

online resource termed Thoracic Surgery Curriculum (TSC) based on the learning management system Moodle.

Available to all residents and faculty in the United States, TSC and the electronic content library, known as

WebBrain, contain peer-reviewed materials, such as review articles, book chapters, video lectures, and TSRA

reviews and case scenarios.7 Categorized into four main headings, including core surgical foundation,


8

cardiovascular surgery, thoracic surgery, and congenital heart surgery, the topics in WebBrain are directly based

on the ABTS curriculum and subdivided into knowledge, patient management and clinical skills, and technical

skills (Figure 2). TSC provides a framework for the resident to study 88 topics in adult cardiovascular surgery,

thoracic surgery, and congenital heart surgery during residency.8,9 Each topic in TSC has basic and advanced

sections with the content linked to specific references in WebBrain. Additionally, quiz questions from previous

Self Education/Self Assessment in Thoracic Surgery (SESATS) are incorporated into the TSC program.

Seven TSC sample templates (3 for two-year traditional program, 2 for three-year traditional programs,

and 2 for integrated-6 programs), all of which can be modified, assist in customizing a curriculum.8 The

expectation is that upon completion of a traditional or integrated residency program, all basic and advanced

content will have been reviewed. One approach specific to the integrated program is to use the 3-year basic TSC

followed by the 3-year advanced TSC. That is, for R1-3 residents, the focus is on the basic level of content of

the 88 topics divided over 3 years; for R4-6 residents, the concentration is on the advanced levels of the same

topics over 3 years (Figure 3).8 Thus, all residents can attend the same didactic conferences with interaction

gauged to the level of training. Generally, the residents are assigned the topic for review the week before the

conference. One resident assigned to that topic can lead the session, with an assigned faculty member directing

the discussion of relevant concepts, and additional educational materials, such as journal articles (e.g., from

WebBrain), TSRA case scenarios, and recent cases, used to supplement the discussion. Alternatively, two topics

can be covered per session, with an assigned faculty member leading each discussion. The conference can be

concluded with resident assessment during a question and answer session with relevant questions from SESATS

on the TSC website. At many institutions, the weekly conference is supplemented with a weekly/monthly

mortality and morbidity conference, monthly journal club, weekly congenital cardiac surgery lecture, weekly

thoracic surgery lecture, and weekly combined cardiology/cardiac surgery conference.

In addition to the CT surgery curriculum and because of the accelerated pace of the integrated program,

the residents are expected to complete the requisite readings and attend the conferences during their respective


9

rotations. Thus, the resident should have an understanding of common general surgery disorders, pre- and

postoperative management of the general surgery patient, principles in cardiology including imaging modalities,

and the current state of endovascular technology.

Technical Skills Education

Technical skills training in CT surgery has been predicated on intraoperative practice and performance.

In the I-6 environment, residents are introduced to surgical skills during their general surgery rotations and CT

surgery rotations in their junior years (R1-R3); typically, at the R4-R6 level, residents are participating in cases

as surgeon. In order to ensure graduated training of technical skills and crisis management, training of

integrated residents prompts consideration of extending operating room teaching into the skills laboratory.

Efforts to advance skills training using simulation include the annual TSDA Boot Camp, which provides

training in cardiopulmonary bypass, vessel anastomosis, aortic valve surgery, bronchoscopy and

mediastinoscopy, and pulmonary resection using synthetic and tissue-based models.10-12 Along with directing

resources to develop novel simulators and assessment tools, the Boot Camp with the Senior Tour has

established a venue to educate faculty in simulation-based learning.12 Crisis management and exposure to rare

events, such as the difficult or obstructed airway, vascular injury during lobectomy, massive air embolus during

cardiopulmonary bypass, and intraoperative aortic dissection, have been beneficial and serve as the basis for the

broader application of simulation. A few years ago, the JCTSE proposed a 92-page curriculum to serve as a

template for simulation training.13 Currently, a 42-week syllabus is being developed by a cardiac surgery study

group sponsored by the Agency for Healthcare Research and Quality.

At many integrated programs, residents are encouraged to use sessions in the skills laboratory to

improve their technical ability. In the skills laboratory using synthetic and tissue-based models, the junior

residents (R1-R3) are taught the fundamentals of surgery, such as knot-tying, basic suturing, and instrument and

tissue handling; additionally, these residents are taught principles of aortic cannulation, coronary artery

anastomosis, and aortic valve replacement with particular emphasis on handling cardiac instruments. Sessions


10

for senior residents (R4-R6) are focused on cardiopulmonary bypass, aortic and mitral valve replacement,

coronary artery anastomosis, crisis management, and potential complications in the perioperative period using

tissue-based simulators.

Because of the requirement from the Thoracic Surgery RRC that all residency programs include

simulation training and the ABTS mandate of a minimum of 20 hours of simulation during residency, efforts

directed at a robust simulation curriculum is of critical importance in the training of integrated residents.

Acknowledging the benefits of practice in a simulation environment, this approach can be costly and labor

intensive.5 Scheduled simulation sessions may conflict with resident clinical responsibilities, and faculty may

not be financially compensated for teaching in such a setting. In order for practice in the skills laboratory to be

of benefit, a strong institutional commitment is absolutely required.

Measuring proficiency

In general, methods of assessment in the I-6 programs do not differ substantially from those in

traditional programs. I-6 residents take an annual in-training examination administered by the TSDA, which

provides an ongoing, standardized evaluation of residents’ knowledge. In many institutions, in the first one or

two years, resident also take the ABS in-training examination. Mock oral examinations often serve as a method

of evaluation and can be employed as preparation for the ABTS certifying examination. Evaluation at the end of

rotation by the faculty and in some cases by a multi-source assessment (faculty, nursing, and ancillary staff) can

document resident performance. Direct observation is typically used in most programs to assess intraoperative

technical skills and patient management on rounds. Technical skills can also be evaluated in the skills

laboratory; at some institutions, such evaluations are performed on a biannual basis using assessment forms

developed by the JCTSE (Figure 4).14

In 1999, the Accredited Council for Graduate Medical Education (ACGME) identified six core

competencies (patient care, medical knowledge, practice-based learning and improvement, professionalism,

interpersonal communication skills, and systems-based practice) for programs to instruct and evaluate residents


11

in training.15 To address the shortcomings of the original core competencies, the ACGME initiated the Next

Accreditation System (NAS) of which a major component is the Milestone Project.15 Specialty-specific

developmental outcomes within each core competency are to be collected by the program and reported

biannually to the ACGME. To be implemented in July 2014, the thoracic surgery Milestone Project requires

defining the assessment methods to the milestones, including defining resident progress in medical knowledge

and patient care for 10 representative topics or diseases. Current efforts are focused on methods to couple data

collection for the Milestones Project with TSC and Moodle. For instance, for the topic of coronary artery

disease, resident progress relating to the medical knowledge and patient care sections can be in part documented

by direct observation, mock oral examinations, case discussions, and in-training examination results (Table 1).

Additionally, the technical skills components can be documented based on direct observation in the operating

room and in the skills laboratory using the assessment form developed by the JCTSE. On a biannual basis, for

instance, mock oral exams and technical skills assessment (direct observation and/or video-recorded

performance) in the skills laboratory or in the operating room are documented. Furthermore, courses developed

within Moodle are accompanied by assessments and can aid in tracking the learner’s progress.5

Challenges

The development and implementation of a I-6 CT residency may pose significant challenges. First, the

ABS case requirements mandate that the I-6 residents obtain substantial general surgery experience and as such,

there may be negative interactions with both general surgery faculty and residents who may feel that is not

appropriate to provide I-6 CT residents with valuable ABS index cases which they will likely never perform

once they are in practice. As stated previously, it is important to maintain a collegial relationship with the

general surgery program director and in this regard it is useful to prioritize the provision of thoracic surgical

cases to the general surgery residents as necessary for their American Board of Surgery requirements. This

priority should be disseminated down to the CT surgery residents so that they also are monitoring the case logs


12

of the general surgery residents that rotate on cardiothoracic surgery to make sure that they are given an

adequate volume of cases.

Similarly, the program directors may encounter push back from members of other specialties that feel

threatened by I--6 residents training in other disciplines. Recognizing that CT surgery is becoming less invasive

as is true for all surgical specialties, I-6 CT surgical residents must become conversant with catheter-based and

minimally invasive techniques, many of which best obtained through off-service rotations. Every effort should

be made to establish collegial relationships with cardiology, interventional radiology, and vascular surgery

colleagues to allow I-6 residents to obtain the necessary experience.

Secondly, in contrast of the traditional trainees who have completed a formal general surgery residency

and as such, may have performed over one thousand cases prior to beginning CT surgery training, I-6 residents

begin training with very limited experience. Thus, a thoughtful graduated approach to surgical training is

important and should be supplemented with additional skills training as appropriate (i.e. simulation-based

training).

Because I-6 residents have had little or no post graduate clinical training, faculty members must modify

their expectations, and increased oversight, patience and understanding are required to ensure that the residents’

training is optimized to achieve competence. Involvement with upper level residents is essential in this regard.

Lastly, one particular challenge facing the I-6 program has been difficulty the inconsistent or lack of

training in laboratory research during residency. Such deficiency compromises the development of future

academic CT surgeons. A recent I-6 CT Residency applicant survey indentified that 91.4% of applicants were

interested in academic careers, and 58.3% were interested in dedicated research time.16 Hence, this deficiency

requires serious consideration amoung the CT surgery leadership. The RRC requires that residents be actively

engaged in research and therefore resources must be made available for I-6 residents to complete at the Medical

University of South Carolina we require residents complete a project every three years at minimum. Clinical

research, case reports, textbook chapters are usually achievable. In some cases, engaged residents may conceive


13

of an extencsive project such as a prospective outcomes-based study which, with assistance and institutional

approval, can be completed during residency. Basic science research is difficult to achieve without a dedicated

rotation but can be successfully executed by extremely motivated trainees. Thus, a standardized approach to

the timing and incorporation of research into the I-6 paradigm remains a challenge that requires further

leadership consideration.

Conclusions

Considerable faculty commitment is required to successfully transition from a traditional CT surgery

training program to an I-6 CT residency paradigm. Because there are no guidelines for the I-6 rotation structure

other than conforming to ABTS case requirements, program directors have considerable freedom in designing

rotation blocks that provide residents with comprehensive training in cardiovascular and thoracic disorders.

Current efforts have centered on restructuring existing models and developing novel tools such online

instruction and simulation-based learning. Resources from the JCTSE, ABTS, TSDA and TSRA have been

directed to address concerns in the I-6 paradigm, one of which is to ensure that all residents be exposed to a

standard curriculum. In order to ensure graduated training of technical skills, training of I-6 residents prompts

consideration of extending operating room teaching into the skills laboratory. Programs have found that

institution of an I-6 CT residency paradigm has resulted in an increase in the both the number and quality of the

applicants.17 While this training paradigm could and probably should be considered an experiment, early

experience has appeared to bolster interest in cardiothoracic surgery among medical students and as such,

carries potential for attracting some of the “best and the brightest” young physicians to our specialty.


14

References

1. Alexander J. The training of a surgeon who expects to specialize in thoracic surgery. J Thorac Surg.

1936;5:579-82.

2. Crawford FA. Presidential address: Thoracic surgery education—responding to a changing environment.

J Thorac Surg. 2003;5:1235-42.

3. Crawford FA. Thoracic surgery education. Ann Thorac Surg 2000;69:330-3.

4. Yaghoubian A, Galante J, Kaji A, Reeves M, Melcher M, Salim A, Dolich M, de Virgilio C. General

surgery resident remediation and attrition: a multi-institutional study. Arch Surg. 2012;147:829-833.

5. Vaporciyan AA, Yang SC, Baker CJ, Fann JI, Verrier ED. Cardiothoracic surgery residency training:

past, present, and future. J Thorac Cardiovasc Surg 2013;146:759-767.

6. Lewis FR, Klingensmith ME. Issues in general surgery residency training. Ann Surg 2012; 256:553-559.

7. WebBrain website: http://jctse.webbrain.com/brainpage/brain/4A8FEA33-71BC-90DC-7808-

4292A8A6D1B4/thought/1 (accessed January 4, 2014).

8. TSDA TSC website: http://www.tsda.org/education/thoracic-surgery-curricula/ (accessed January 4,

2014).

9. JCTSE TSC website: http://jctse.mrooms.net/ (accessed January 4, 2014).

10. Fann JI, Calhoon JH, Carpenter AJ, Merrill WH, Brown JW, Poston RS, Kalani M, Murray GF, Hicks

GL Jr, Feins RH. Simulation in coronary artery anastomosis early in cardiothoracic surgical residency

training: The Boot Camp experience. J Thorac Cardiovasc Surg 2010;139:1275-1281.

11. Hicks GL, Jr, Gangemi J, Angona RE, Jr, Ramphal PS, Feins RH, Fann JI. Cardiopulmonary bypass

simulation at the Boot Camp. J Thorac Cardiovasc Surg 2011;141:284-292.

12. Fann JI, Feins RH, Hicks GL, Jr, Nesbitt JC, Hammon JW, Crawford FA, Jr, Senior Tour in

Cardiothoracic Surgery. Evaluation of simulation training in cardiothoracic surgery: The Senior Tour

perspective. J Thorac Cardiovasc Surg 2012;143:264-272.


15

13. JCTSE Simulation curriculum: http: //www.jctse.org/education/simulation/ (accessed January 4, 2014).

14. JCTSE Skills assessment: http://www.jctse.org/education/jctse-assessments/ (accessed January 4,

2014).

15. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system: rationale and benefits.

N Engl J Med 2012;366:1051-1056.

16. 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;146:753-758.

17. Gasparri MG, Tisol WB, Masroor S. Impact of a six-year integrated thoracic surgery training program at

the Medical College of Wisconsin. Ann Thorac Surg 2012;93:592-595.


16

Table 1: Potential methods to document performance for the Thoracic Surgery Milestones Project

Medical Knowledge: ITE SESATS Mock oral exam Direct observation Case discussions

Patient Care and Technical Skills ITE

SESATS Mock oral exam Direct observation Case logs Case discussion

Interpersonal Communication Skills: Direct observation

Multi-source evaluation (360o ) Mock oral exam Chart review

Practice-based Learning and Improvement: Case logs

Chart review Patient outcomes

Professionalism: Direct observation

Multi-source evaluation (360o ) Systems-based Practice: Direct observation

Multi-source evaluation (360o ) Chart review

Case discussions ITE: Thoracic surgery in-training examination; SESATS: Self Education/Self Assessment in Thoracic Surgery.


17

Figure legends

Figure 1. Sample rotation block for the I-6 cardiothoracic residency training paradigm as used at the

Medical University of South Carolina.

Figure 2. A. Picture of web-page of the learning content management system WebBrain, which is

categorized into four main headings, including core surgical foundation, cardiovascular surgery, thoracic

surgery, and congenital heart surgery. B. By clicking on cardiovascular surgery and heart valve disease,

for instance, subheadings such as aortic valve disease, endocarditis, mitral valve disease, and tricuspid

valve disease are demonstrated. Also, note that other topics of cardiovascular surgery are listed, e.g.,

cardiac conduction system disorders, cardiopulmonary bypass and cardiothoracic trauma, etc.

Figure 3. Sample page from the Thoracic Surgery Curriculum, which is based on the American Board

of Thoracic Surgery curriculum. Topics, organized by weeks, are divided into basic and advanced levels

with links directly to the learning management system Moodle on the Joint Council on Thoracic Surgery

Education website.

Figure 4A and 4B. Sample page from the assessment form for coronary artery bypass grafting based on

a 5-point scale. Assessment may be based on direct observation in the operating room or in the skills

laboratory. The importance of the assessment form is to better document resident skills performance, to

increase resident motivation, and to develop methods for remediation.


18

Fig 1


19

Fig 2a

Fig 2b


20

Fig 3


21

Fig 4a


22

Fig 4b

Documents

Integrated Surgical Residency Initiative: Implications for Cardiothoracic Surgery