A Decade of Change: Training and Career Paths of Cardiothoracic Surgery Residents 2003 to 2014
Department of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, New York; Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia; Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia; Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington; Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Division of General Thoracic Surgery, Baylor College of Medicine, Houston, Texas; Pinnacle Health CardioVascular Institute, Harrisburg, Pennsylvania; Department of Surgery, Duke University, Durham, North Carolina; Division of Cardiac Surgery, Northwestern University, Chicago, Illinois; Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Division of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, New York; Department of Surgery, Congenital Heart Surgery, Texas Children’s Hospital, Houston, Texas; Department of Cardiothoracic Surgery, University of Iowa, Iowa City, Iowa; Division of Cardiothoracic Surgery, University of Mississippi, Oxford, Mississippi; Department of Cardiothoracic and Vascular Surgery, University of Texas Memorial Hermann-Texas Medical Center, Houston, Texas
Background. During the past decade, cardiothoracic surgery (CTS) education has undergone tremendous change with the advent of new technologies and the implementation of integrated programs, to name a few. The goal of this study was to assess how residents’ career paths, training, and perceptions changed during this period. Methods. The 2006 to 2014 surveys accompanying the Thoracic Surgery Residents Association/Thoracic Surgery Directors’ Association in-training examination taken by CTS residents were analyzed, along with a 2003 survey of graduating CTS residents. Of 2,563 residents surveyed, 2,434 (95%) responded. Results. During the decade, fewer residents were interested in mixed adult cardiac/thoracic practice (20% in 2014 vs 52% in 2003, p [ 0.004), more planned on additional training (10% in 2003 vs 41% to 47% from 2011 to 2014), and the frequent use of simulation increased from 1% in 2009 to 24% in 2012 (p < 0.001). More residents
recommended CTS to potential trainees (79% in 2014 vs 65% in 2010, p [ 0.007). Job offers increased from a low of 12% in 2008 with three or more offers to 34% in 2014. Debt increased from 0% with more than $200,000 in 2003 to 40% in 2013 (p < 0.001). Compared with residents in traditional programs, more integrated residents in 2014 were interested in adult cardiac surgery (53% vs 31%) and congenital surgery (22% vs 7%), fewer were interested in general thoracic surgery (5% vs 31%, p < 0.001), and more planned on additional training (66% vs 36%, p < 0.001). Conclusions. With the evolution in CTS over the last decade, residents’ training and career paths have changed substantially, with increased specialization and simulation accompanied by increased resident satisfaction and an improved job market.
C
with implementation of nation-wide curricula, online resources, and simulation [1]. The implementation of workhour restrictions has demanded optimization of how the next generation of CTS residents is taught, with many programs supplementing their training with simulation. One of the most dramatic changes in CTS education has been the increasing adoption of the integrated cardiothoracic training paradigm. Although these changes have been well documented, how these changes have affected residents’ career paths and perceptions of the specialty and their training during this period have not been assessed. Following the pioneering work of Lee and colleagues [2] and the Thoracic
ardiothoracic surgery (CTS) has evolved substantially during the last decade with the advent of transcatheter valves, expanding use and repertoire of mechanical assist devices, as well as minimally invasive and robotic techniques. Accompanying our specialty’s transformation have been advances in CTS education
Accepted for publication April 1, 2015. Presented at the Fifty-first Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 24–28, 2015. Address correspondence to Dr Nguyen, 6400 Fannin St, Ste 2850, Houston, TX 77030; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;100:1305–14) Ó 2015 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.04.026
ADULT CARDIAC
Elizabeth H. Stephens, MD, PhD, David Odell, MD, William Stein, MD, Damien J. LaPar, MD, MS, Walter F. DeNino, MD, Muhammad Aftab, MD, Kathleen Berfield, MD, Amanda L. Eilers, DO, Shawn Groth, MD, John F. Lazar, MD, Michael P. Robich, MD, MPH, Asad A. Shah, MD, Danielle A. Smith, MD, Cameron Stock, MD, Vakhtang Tchantchaleishvili, MD, Carlos M. Mery, MD, MPH, Joseph W. Turek, MD, PhD, Jorge Salazar, MD, and Tom C. Nguyen, MD
ADULT CARDIAC
1306
STEPHENS ET AL CAREER PATHS AND TRAINING OF CTS RESIDENTS
Surgery Residents Association (TSRA) in polling CTS residents’ perceptions and career paths in 2002, TSRA surveys now accompany the yearly in-training examination (ITE) taken by CTS residents. Using these surveys to evaluate residents’ perceptions and career paths may allow further refinement of how to best educate the next generation of cardiothoracic surgeons. To this end we used surveys of CTS residents from 2003 to 2014 to focus on three key areas during the last decade: (1) resident perception of training and the specialty, (2) career pathways, and (3) job market.
Material and Methods The 2006 to 2014 surveys accompanying the ITE taken by current CTS residents were analyzed along with a 2003 survey sent to graduating CTS residents. From 2007 to 2014 the survey was mandatory, whereas in 2006 and 2003 the survey was optional. There were no surveys accompanying the ITE in 2003 to 2005. Residents in nonaccredited fellowships were excluded. Changes over the years were compared with c2 testing and with post hoc testing. Subgroup analyses of the 2014 data assessed for potentially distinct populations within the residents in specialty interests and career paths. Comparisons were made between integrated and traditional residents (residents in 4þ3 programs were excluded from those analyses) and those interested in academic vs private practice. Logistic regression analysis was used to assess for an association between postgraduate year and additional training. Only the mean response rate was available for 2006 to 2009, thus preventing statistical comparison between these and the remaining years. SPSS 22.0 software (IBM Corp, Armonk, NY) was used for analysis. A p value of 0.05 or less was considered statistically significant.
Results Response Rate The response rate was 100% for 2007 to 2014, 54% in 2006, and 64% in 2003, for an overall response rate of 95% (2,434 of 2,563). Fig 1. Percentage of residents in integrated programs.
Ann Thorac Surg 2015;100:1305–14
Career Pathways: Program Types, Specialty Interests, and Additional Training As expected, given the advent of integrated programs, from 2003 to 2014 the percentage of residents in integrated programs increased from 0% in 2003 to 28% in 2014 (Fig 1). Specialty interests have changed over time, with decreasing interest in mixed cardiac/thoracic surgery (47% in 2003 vs 16% in 2014, p ¼ 0.004; Table 1, Fig 2) and a corresponding tendency to focus on adult cardiac surgery (33% in 2003 vs 39% in 2014) or thoracic surgery (15% in 2003 vs 23% in 2014). These changes in specialty interest were also statistically significant when graduating residents were examined. In recent years, more residents planned on pursuing additional training (40% to 47% in 2010 to 2014 vs 10% in 2003), most commonly in congenital heart surgery (24% to 31% in 2010 to 2014, Table 1). Logistic regression analysis did not show an association between postgraduate year and intention to pursue additional training. In 2013 there was the opportunity to select the reason for additional training. The most common reason for additional training was to allow for a specialized/niche practice (45% of residents), 21% cited additional training was for attaining additional skills not taught in their program, 7% to be competitive for the job they want, 4% because they did not feel adequately trained, 1% because they could not find a job, and 3% for other reasons. Over the course of the years, there has not been a significant change in academic vs private practice careers.
Perception of Adequacy of Training and Preparation for Boards In 2014, 89% of respondents (Fig 3) felt they were adequately trained after residency, which was increased from 79% in 2009 but was decreased from 97% in 2003. In 2003, 89% of respondents felt adequately prepared for the boards in 2003, but this decreased to 76% in 2013 and to 80% in 2014 (p < 0.05).
Ann Thorac Surg 2015;100:1305–14
STEPHENS ET AL CAREER PATHS AND TRAINING OF CTS RESIDENTS
1307
Table 1. Specialty and Additional Traininga
Variable
2010 (n ¼ 299) No. (%)
2011 (n ¼ 305) No. (%)
2012 (n ¼ 313) No. (%)
2013 (n ¼ 317) No. (%)
2014 (n ¼ 317) No. (%)
29 42 13 5
(33) (47)A (15) (6) NA NA NA
93 69 66 30 14 15 5
108 60 61 31 18 10 3
108 62 72 30 23 3 4
127 52 77 32 12 7 7
121 51 72 42 11 15 1
NA NA NA
9 (8) 34 (30) NA
17 (14) 30 (24) NA
12 (10) 33 (26) NA
20 (14) 40 (27) 15 (10)
22 (16) 43 (31) 13 (9)
NA NA NA NA
12 13 21 26
24 17 15 23
19 20 12 29
18 17 13 25
15 13 14 19
p Value $200,000). Data do not take into account inflation. ADULT CARDIAC
Career Pathways: Increased Specialization and Additional Training Over the years the number of residents entering mixed cardiac/thoracic practices has decreased, with more focusing on cardiac or thoracic surgery and more residents pursuing additional training. During this time the field has become increasingly specialized, requiring specific skill sets and knowledge bases; for example, an endovascular skill set is required in the case of transcatheter aortic valve replacement, and with the increasing array of ventricular assist devices, specific knowledge and experience with individual devices is necessary. Some may argue that the increase in additional training reflects a deficiency in training because graduates do not feel adequately prepared. However, this more likely reflects the complexity and increasing subspecialization of the field such that a base of knowledge is acquired during fellowship and specialized techniques are obtained during periods of additional
training [3]. Indeed, the 2013 data show that the vast majority of residents were pursuing additional training to have a specialty practice, to refine skills learned in their program, or to obtain skills not taught in their program, and only 4% were pursuing additional training because they felt inadequately trained.
Expanding Job Market Although in previous years (2007 to 2008, 2011) 35% to 40% had no job offers by March, that decreased to 20% in the last 3 years. Meanwhile, 30% to 34% had three or more offers compared with 12% in 2008, suggesting an improved job market. However, debt has increased substantially, with 43% graduating with debt exceeding $200,000; this increase in debt remains substantial despite the approximately 29% inflation over the span of the study. Increasing debt does not appear to be influencing residents’ choice of private careers over academic careers.
Perception of the Specialty
Fig 6. Percentage of residents who would recommend cardiothoracic surgery (CTS) to trainees. The p value represents the overall p value comparing all years. For a given variable, data points with different letters were statistically significantly different on post hoc testing, whereas data points with the same letter or no letters were not statistically significantly different. (Blue line, agree; red line, neutral; green line, disagree.)
Since 1994 the number of applicants to traditional CTS fellowships has steadily declined [4]. The reasons behind this decline and potential ways to increase interest in CTS have been extensively discussed [5]. Length of training, job security, lifestyle, and concerns regarding the future of the specialty have been considered contributing factors [4, 6, 7], as highlighted in the initial 2002 TSRA survey polling graduating CTS residents [2]. Potential trainees exposed to cardiothoracic surgeons and fellows satisfied by their career choice will help recruit more to the specialty. Our data show that residents are increasingly satisfied with their career choice: 79% in 2012 would recommend CTS to potential trainees in 2012 compared with 59% in 2009. As in other studies [8, 9], mentorship was key to career choice as well as personal experience and case variety. These results confirm the importance of exposure to the specialty, allowing residents to observe the case variety and find mentorship. For integrated programs, this exposure must occur in medical school or before, hence, the
ADULT CARDIAC
1310
STEPHENS ET AL CAREER PATHS AND TRAINING OF CTS RESIDENTS
Ann Thorac Surg 2015;100:1305–14
Fig 7. Study aids for the in training exam. (Blue line, Thoracic Surgery Residents’ Association (TSRA) Review; red line, Thoracic Surgery Directors’ Association (TSDA) curriculum; green line, Self Education Self Assessment in Thoracic Surgery (SESATS); turquoise line, textbooks; blue line, TSRA clinical scenarios.)
efforts by the Joint Council for Thoracic Surgery Education [6] and national societies to increase exposure of younger students to the field.
Perception of CTS Educational Resources: Increasing Use of TSDA/TSRA Resources and Simulation With the increasing interest in CTS education and efforts to optimize education in light of work-hour restrictions, the Joint Council for Thoracic Surgery Education and TSDA have invested heavily in providing programs with curricular resources. Most recently in August 2013 the thoracic “brain”/“Moodle” was launched, providing a comprehensive system with a wide variety of searchable resources, structured curriculum, and ability for the resident and program to both monitor resident progress. The TSRA has also
Fig 8. Percentage of residents who frequently (blue line), occasionally (red line), or rarely (green line) use simulation. The p value represents the overall p value comparing all years. For a given variable, data points with different letters were statistically significantly different on post hoc testing, whereas data points with the same letter or no letters were not statistically significantly different.
invested heavily in improving educational resources, including publishing the TSRA Review and TSRA Clinical Scenarios. Unfortunately, the survey in 2014 did not include a question querying the residents’ perception of the thoracic “brain”/“Moodle,” but the TSDA curriculum was increasingly used as a study aid for the ITE, as was the TSRA Review, while reliance on Self Education Self Assessment in Thoracic Surgery and textbooks (both online and paper) decreased. Therefore, the educational resources provided by the TSDA/Joint Council for Thoracic Surgery Education and TSRA appear to have found a substantial role in the training of residents. Given the work-hour restrictions and inherent limitations of learning operative techniques in the operating room, attention has turned to simulation as an
Ann Thorac Surg 2015;100:1305–14
STEPHENS ET AL CAREER PATHS AND TRAINING OF CTS RESIDENTS
1311
Table 2. Comparison of 2014 Integrated and Traditional Residents
Variable
a
Traditional (n ¼ 200 [69%]) No. (%)
p Value
Department of Cardiac, Thoracic and Vascular Surgery, Columbia University, New York, New York; Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia; Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia; Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington; Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas; Division of General Thoracic Surgery, Baylor College of Medicine, Houston, Texas; Pinnacle Health CardioVascular Institute, Harrisburg, Pennsylvania; Department of Surgery, Duke University, Durham, North Carolina; Division of Cardiac Surgery, Northwestern University, Chicago, Illinois; Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Division of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, New York; Department of Surgery, Congenital Heart Surgery, Texas Children’s Hospital, Houston, Texas; Department of Cardiothoracic Surgery, University of Iowa, Iowa City, Iowa; Division of Cardiothoracic Surgery, University of Mississippi, Oxford, Mississippi; Department of Cardiothoracic and Vascular Surgery, University of Texas Memorial Hermann-Texas Medical Center, Houston, Texas
Background. During the past decade, cardiothoracic surgery (CTS) education has undergone tremendous change with the advent of new technologies and the implementation of integrated programs, to name a few. The goal of this study was to assess how residents’ career paths, training, and perceptions changed during this period. Methods. The 2006 to 2014 surveys accompanying the Thoracic Surgery Residents Association/Thoracic Surgery Directors’ Association in-training examination taken by CTS residents were analyzed, along with a 2003 survey of graduating CTS residents. Of 2,563 residents surveyed, 2,434 (95%) responded. Results. During the decade, fewer residents were interested in mixed adult cardiac/thoracic practice (20% in 2014 vs 52% in 2003, p [ 0.004), more planned on additional training (10% in 2003 vs 41% to 47% from 2011 to 2014), and the frequent use of simulation increased from 1% in 2009 to 24% in 2012 (p < 0.001). More residents
recommended CTS to potential trainees (79% in 2014 vs 65% in 2010, p [ 0.007). Job offers increased from a low of 12% in 2008 with three or more offers to 34% in 2014. Debt increased from 0% with more than $200,000 in 2003 to 40% in 2013 (p < 0.001). Compared with residents in traditional programs, more integrated residents in 2014 were interested in adult cardiac surgery (53% vs 31%) and congenital surgery (22% vs 7%), fewer were interested in general thoracic surgery (5% vs 31%, p < 0.001), and more planned on additional training (66% vs 36%, p < 0.001). Conclusions. With the evolution in CTS over the last decade, residents’ training and career paths have changed substantially, with increased specialization and simulation accompanied by increased resident satisfaction and an improved job market.
C
with implementation of nation-wide curricula, online resources, and simulation [1]. The implementation of workhour restrictions has demanded optimization of how the next generation of CTS residents is taught, with many programs supplementing their training with simulation. One of the most dramatic changes in CTS education has been the increasing adoption of the integrated cardiothoracic training paradigm. Although these changes have been well documented, how these changes have affected residents’ career paths and perceptions of the specialty and their training during this period have not been assessed. Following the pioneering work of Lee and colleagues [2] and the Thoracic
ardiothoracic surgery (CTS) has evolved substantially during the last decade with the advent of transcatheter valves, expanding use and repertoire of mechanical assist devices, as well as minimally invasive and robotic techniques. Accompanying our specialty’s transformation have been advances in CTS education
Accepted for publication April 1, 2015. Presented at the Fifty-first Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 24–28, 2015. Address correspondence to Dr Nguyen, 6400 Fannin St, Ste 2850, Houston, TX 77030; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;100:1305–14) Ó 2015 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.04.026
ADULT CARDIAC
Elizabeth H. Stephens, MD, PhD, David Odell, MD, William Stein, MD, Damien J. LaPar, MD, MS, Walter F. DeNino, MD, Muhammad Aftab, MD, Kathleen Berfield, MD, Amanda L. Eilers, DO, Shawn Groth, MD, John F. Lazar, MD, Michael P. Robich, MD, MPH, Asad A. Shah, MD, Danielle A. Smith, MD, Cameron Stock, MD, Vakhtang Tchantchaleishvili, MD, Carlos M. Mery, MD, MPH, Joseph W. Turek, MD, PhD, Jorge Salazar, MD, and Tom C. Nguyen, MD
ADULT CARDIAC
1306
STEPHENS ET AL CAREER PATHS AND TRAINING OF CTS RESIDENTS
Surgery Residents Association (TSRA) in polling CTS residents’ perceptions and career paths in 2002, TSRA surveys now accompany the yearly in-training examination (ITE) taken by CTS residents. Using these surveys to evaluate residents’ perceptions and career paths may allow further refinement of how to best educate the next generation of cardiothoracic surgeons. To this end we used surveys of CTS residents from 2003 to 2014 to focus on three key areas during the last decade: (1) resident perception of training and the specialty, (2) career pathways, and (3) job market.
Material and Methods The 2006 to 2014 surveys accompanying the ITE taken by current CTS residents were analyzed along with a 2003 survey sent to graduating CTS residents. From 2007 to 2014 the survey was mandatory, whereas in 2006 and 2003 the survey was optional. There were no surveys accompanying the ITE in 2003 to 2005. Residents in nonaccredited fellowships were excluded. Changes over the years were compared with c2 testing and with post hoc testing. Subgroup analyses of the 2014 data assessed for potentially distinct populations within the residents in specialty interests and career paths. Comparisons were made between integrated and traditional residents (residents in 4þ3 programs were excluded from those analyses) and those interested in academic vs private practice. Logistic regression analysis was used to assess for an association between postgraduate year and additional training. Only the mean response rate was available for 2006 to 2009, thus preventing statistical comparison between these and the remaining years. SPSS 22.0 software (IBM Corp, Armonk, NY) was used for analysis. A p value of 0.05 or less was considered statistically significant.
Results Response Rate The response rate was 100% for 2007 to 2014, 54% in 2006, and 64% in 2003, for an overall response rate of 95% (2,434 of 2,563). Fig 1. Percentage of residents in integrated programs.
Ann Thorac Surg 2015;100:1305–14
Career Pathways: Program Types, Specialty Interests, and Additional Training As expected, given the advent of integrated programs, from 2003 to 2014 the percentage of residents in integrated programs increased from 0% in 2003 to 28% in 2014 (Fig 1). Specialty interests have changed over time, with decreasing interest in mixed cardiac/thoracic surgery (47% in 2003 vs 16% in 2014, p ¼ 0.004; Table 1, Fig 2) and a corresponding tendency to focus on adult cardiac surgery (33% in 2003 vs 39% in 2014) or thoracic surgery (15% in 2003 vs 23% in 2014). These changes in specialty interest were also statistically significant when graduating residents were examined. In recent years, more residents planned on pursuing additional training (40% to 47% in 2010 to 2014 vs 10% in 2003), most commonly in congenital heart surgery (24% to 31% in 2010 to 2014, Table 1). Logistic regression analysis did not show an association between postgraduate year and intention to pursue additional training. In 2013 there was the opportunity to select the reason for additional training. The most common reason for additional training was to allow for a specialized/niche practice (45% of residents), 21% cited additional training was for attaining additional skills not taught in their program, 7% to be competitive for the job they want, 4% because they did not feel adequately trained, 1% because they could not find a job, and 3% for other reasons. Over the course of the years, there has not been a significant change in academic vs private practice careers.
Perception of Adequacy of Training and Preparation for Boards In 2014, 89% of respondents (Fig 3) felt they were adequately trained after residency, which was increased from 79% in 2009 but was decreased from 97% in 2003. In 2003, 89% of respondents felt adequately prepared for the boards in 2003, but this decreased to 76% in 2013 and to 80% in 2014 (p < 0.05).
Ann Thorac Surg 2015;100:1305–14
STEPHENS ET AL CAREER PATHS AND TRAINING OF CTS RESIDENTS
1307
Table 1. Specialty and Additional Traininga
Variable
2010 (n ¼ 299) No. (%)
2011 (n ¼ 305) No. (%)
2012 (n ¼ 313) No. (%)
2013 (n ¼ 317) No. (%)
2014 (n ¼ 317) No. (%)
29 42 13 5
(33) (47)A (15) (6) NA NA NA
93 69 66 30 14 15 5
108 60 61 31 18 10 3
108 62 72 30 23 3 4
127 52 77 32 12 7 7
121 51 72 42 11 15 1
NA NA NA
9 (8) 34 (30) NA
17 (14) 30 (24) NA
12 (10) 33 (26) NA
20 (14) 40 (27) 15 (10)
22 (16) 43 (31) 13 (9)
NA NA NA NA
12 13 21 26
24 17 15 23
19 20 12 29
18 17 13 25
15 13 14 19
p Value $200,000). Data do not take into account inflation. ADULT CARDIAC
Career Pathways: Increased Specialization and Additional Training Over the years the number of residents entering mixed cardiac/thoracic practices has decreased, with more focusing on cardiac or thoracic surgery and more residents pursuing additional training. During this time the field has become increasingly specialized, requiring specific skill sets and knowledge bases; for example, an endovascular skill set is required in the case of transcatheter aortic valve replacement, and with the increasing array of ventricular assist devices, specific knowledge and experience with individual devices is necessary. Some may argue that the increase in additional training reflects a deficiency in training because graduates do not feel adequately prepared. However, this more likely reflects the complexity and increasing subspecialization of the field such that a base of knowledge is acquired during fellowship and specialized techniques are obtained during periods of additional
training [3]. Indeed, the 2013 data show that the vast majority of residents were pursuing additional training to have a specialty practice, to refine skills learned in their program, or to obtain skills not taught in their program, and only 4% were pursuing additional training because they felt inadequately trained.
Expanding Job Market Although in previous years (2007 to 2008, 2011) 35% to 40% had no job offers by March, that decreased to 20% in the last 3 years. Meanwhile, 30% to 34% had three or more offers compared with 12% in 2008, suggesting an improved job market. However, debt has increased substantially, with 43% graduating with debt exceeding $200,000; this increase in debt remains substantial despite the approximately 29% inflation over the span of the study. Increasing debt does not appear to be influencing residents’ choice of private careers over academic careers.
Perception of the Specialty
Fig 6. Percentage of residents who would recommend cardiothoracic surgery (CTS) to trainees. The p value represents the overall p value comparing all years. For a given variable, data points with different letters were statistically significantly different on post hoc testing, whereas data points with the same letter or no letters were not statistically significantly different. (Blue line, agree; red line, neutral; green line, disagree.)
Since 1994 the number of applicants to traditional CTS fellowships has steadily declined [4]. The reasons behind this decline and potential ways to increase interest in CTS have been extensively discussed [5]. Length of training, job security, lifestyle, and concerns regarding the future of the specialty have been considered contributing factors [4, 6, 7], as highlighted in the initial 2002 TSRA survey polling graduating CTS residents [2]. Potential trainees exposed to cardiothoracic surgeons and fellows satisfied by their career choice will help recruit more to the specialty. Our data show that residents are increasingly satisfied with their career choice: 79% in 2012 would recommend CTS to potential trainees in 2012 compared with 59% in 2009. As in other studies [8, 9], mentorship was key to career choice as well as personal experience and case variety. These results confirm the importance of exposure to the specialty, allowing residents to observe the case variety and find mentorship. For integrated programs, this exposure must occur in medical school or before, hence, the
ADULT CARDIAC
1310
STEPHENS ET AL CAREER PATHS AND TRAINING OF CTS RESIDENTS
Ann Thorac Surg 2015;100:1305–14
Fig 7. Study aids for the in training exam. (Blue line, Thoracic Surgery Residents’ Association (TSRA) Review; red line, Thoracic Surgery Directors’ Association (TSDA) curriculum; green line, Self Education Self Assessment in Thoracic Surgery (SESATS); turquoise line, textbooks; blue line, TSRA clinical scenarios.)
efforts by the Joint Council for Thoracic Surgery Education [6] and national societies to increase exposure of younger students to the field.
Perception of CTS Educational Resources: Increasing Use of TSDA/TSRA Resources and Simulation With the increasing interest in CTS education and efforts to optimize education in light of work-hour restrictions, the Joint Council for Thoracic Surgery Education and TSDA have invested heavily in providing programs with curricular resources. Most recently in August 2013 the thoracic “brain”/“Moodle” was launched, providing a comprehensive system with a wide variety of searchable resources, structured curriculum, and ability for the resident and program to both monitor resident progress. The TSRA has also
Fig 8. Percentage of residents who frequently (blue line), occasionally (red line), or rarely (green line) use simulation. The p value represents the overall p value comparing all years. For a given variable, data points with different letters were statistically significantly different on post hoc testing, whereas data points with the same letter or no letters were not statistically significantly different.
invested heavily in improving educational resources, including publishing the TSRA Review and TSRA Clinical Scenarios. Unfortunately, the survey in 2014 did not include a question querying the residents’ perception of the thoracic “brain”/“Moodle,” but the TSDA curriculum was increasingly used as a study aid for the ITE, as was the TSRA Review, while reliance on Self Education Self Assessment in Thoracic Surgery and textbooks (both online and paper) decreased. Therefore, the educational resources provided by the TSDA/Joint Council for Thoracic Surgery Education and TSRA appear to have found a substantial role in the training of residents. Given the work-hour restrictions and inherent limitations of learning operative techniques in the operating room, attention has turned to simulation as an
Ann Thorac Surg 2015;100:1305–14
STEPHENS ET AL CAREER PATHS AND TRAINING OF CTS RESIDENTS
1311
Table 2. Comparison of 2014 Integrated and Traditional Residents
Variable
a
Traditional (n ¼ 200 [69%]) No. (%)
p Value
