Integrated and Fast-Track Cardiothoracic Surgery Training Programs

Introduction

The current “traditional” method for training cardiothoracic surgeons (five years of general surgery and two-three years of thoracic) dates back 80 years to a time in which the specialty consisted of operations for empyemas and tuberculosis. Needless to say, over the course of the last 80 years, the field of cardiothoracic surgery has changed dramatically. The changing scope of cardiothoracic surgical practice, as well as issues related to difficulty attracting trainees and effective use of training time, has led many leaders in our field to instigate reform in the training process of cardiothoracic residents.

Based on an initial statement provided by the American Board of Thoracic Surgery (ABTS) in 2001 (as discussed in Dr. Fred Crawford’s 2003 AATS Presidential Address1), there are currently three paths for cardiothoracic surgical training: 1) the traditional 5 years of general surgery, complete with American Board of Surgery (ABS) certification, plus 2-3 years in a thoracic fellowship, 2) four years of general surgery, plus 3 years of thoracic fellowship (“fast-track”), all completed at one institution, and 3) an integrated 6-year cardiothoracic surgery residency, leading to ABTS certification. The application process, curriculum, and board certifications involved in each of these pathways vary dramatically, and even vary between institutions that offer these tracks. The purpose of this article is to detail the logistical process for entering the fast-track and integrated programs, profile several institutions with approved integrated or fast-track programs, and discuss potential future changes in the education of cardiothoracic surgeons.

Current Integrated and Fast-Track Programs Offered

Dr. Marc Moon (center), Director of Washington University’s Fast-Track Program, shown operating.

Currently, Accreditation Council for Graduate Medical Education (ACGME)- approved integrated cardiothoracic residencies are being offered by Stanford University (Stanford, CA), University of Pennsylvania (Philadelphia, PA), and Medical University of South Carolina (MUSC, Charleston, SC). Approved “fast-track” or “Joint General Surgery/Thoracic Surgery” programs2 are currently being offered by Brigham and Women’s Hospital/Children’s Hospital Program (Boston, MA), Duke University (Durham, NC), Mayo School of Graduate Medical Education (Rochester, MN), University of Maryland (Baltimore, MD), University of Rochester (Rochester, NY), University of Virginia (Charlottesville, VA), and Washington University School of Medicine (St. Louis, MO).

Integrated Programs

Residents for the integrated program apply in their fourth year of medical school, similar to standard applications for other residency programs. Upon completion of an integrated residency, residents are eligible to sit for ABTS certification, but not ABS certification.

The first ACGME-approved integrated program was Stanford University, which currently has two classes of residents and two positions available each year. The concept of an integrated training program for cardiothoracic surgery at Stanford dates back to 1968, when Dr. Norman Shumway proposed a 6-year integrated program. Stanford’s current, approved program was largely the result of Dr. Robert Robbins (Program Director and Chief of Cardiothoracic Surgery) who envisioned the program and Dr. Michael Fischbein who spearheaded the project. The consensus among faculty in support of the integrated training program has been extraordinary, according to Dr. Robbins. While Stanford is now able to offer such a program, resident training is much more refined, says Dr. Robbins, by including training in emerging technologies related to cardiothoracic surgery and many of the associated “subspecialties,” while maintaining traditional cardiothoracic training.

The curriculum of the Stanford program consists of 6 clinical years. Two years are “prerequisite clinical training” which includes 9 months of general surgery. The other 15 months are divided among rotations in interventional radiology, interventional cardiology, electrophysiology, cardiothoracic anesthesiology, imaging, emergency medicine, cardiac critical care, trauma surgery, and cardiothoracic surgery. The last 4 years are considered “requisite clinical training.” The first year of requisite training consists of adult and pediatric cardiac surgery, thoracic surgery, and interventional cardiology. The remaining 3 years of requisite training consist of the same rotations as Stanford’s traditional cardiothoracic residency, including rotations in adult and pediatric cardiac surgery, endovascular surgery, transplant, and thoracic surgery. The Stanford curriculum is based on a cardiovascular disease-based approach that gives a more complete view to cardiothoracic surgery, Dr. Robbins says, and it should be noted that Stanford’s integrated program has a heavy focus on cardiovascular (as opposed to thoracic) training.

Current Stanford integrated cardiothoracic surgery program residents speak very highly of the faculty’s dedication to the new program. As Dr. Clay Kaiser, a current first year resident stated, the success of this program rides on the faculty’s dedication. Indeed, such a curriculum creates a challenge for the cardiothoracic surgery faculty, who were accustomed to residents fully trained in general surgery entering their program.

The curriculum of the University of Pennsylvania (Penn) integrated program is similar to that of Stanford with 6 years of integrated general surgery and cardiothoracic clinical training and 2 optional years of clinical or basic science research. Training in the first two years of the program is designed to provide concentrated operative experience. These first 2 “prerequisite” years consist of general surgery (17 months), as well as robotic and minimally invasive surgery, cardiac critical care, trauma, and endocrine and oncologic surgery. Residents are assigned to an outside hospital for the majority of their general surgery rotations in which they receive intensive operating experience. The last four years consist of rotations in cardiac surgery and thoracic surgery, as well as pediatric cardiac surgery, endocrine and oncologic surgery, interventional cardiology, cardiac anesthesia, cardiac imaging, and endovascular and vascular surgery. Like Stanford, the Penn integrated program is focused on cardiovascular (as opposed to thoracic) training.

Unlike Stanford, Penn is maintaining their traditional cardiothoracic training program, and in fact, is not required to take a resident for the integrated program each year. In Dr. Michael Acker’s view (Penn Program Director and Chief of Cardiovascular Surgery) there is a place for each pathway depending on the person. Dr. Acker points out that the traditional pathway is the one that we know works well; the new integrated programs are an experiment. In Dr. Acker’s view, the key will be whether the integrated programs can provide enough of a foundation in surgical technique to create truly great cardiothoracic surgeons. While the traditional pathway takes longer, it allows for more exposure to the specialties of surgery before requiring the resident to make a decision on specializing in cardiothoracic surgery. Penn matriculated its first integrated resident in 2008 and has one potential spot for the integrated program per year.

While Dr. Fred Crawford (MUSC Program Director and Chief of Cardiothoracic Surgery) has been a leader in cardiothoracic surgery education for years and has been instrumental in many of the reforms leading to ACGME-approved integrated programs, the impetus for the development of an integrated program at MUSC came from junior faculty, Dr. Crawford says. The Thoracic Surgery Residency Review Committee gave MUSC considerable leeway such that the integrated program at MUSC is significantly different from that of Stanford and Penn. The curriculum for the integrated cardiothoracic program at MUSC does not include years designated for clinical or laboratory research, although the program may evolve to include a mandatory or optional research component. The first two years of the MUSC curriculum consists of 1-2 month clinical rotations providing exposure to fields relevant to cardiothoracic surgery including diagnostic cardiology, imaging, endoscopy, echocardiography, cardiothoracic critical care, surgical oncology, GI surgery, pediatric surgery, vascular surgery, as well as cardiothoracic surgery, transplant, thoracic surgery, and pediatric cardiac surgery. After the initial 2 years, rotations of longer duration provide in-depth training in cardiothoracic surgery, thoracic surgery, and pediatric cardiac surgery, as well as vascular and interventional radiology. An opportunity for a 3-month away elective is also provided. In Dr. Crawford’s view, key advantages to the integrated approach include shorter, more focused training, which will be more attractive to potential applicants, and the inclusion of fields adjunct to cardiothoracic surgery, which are critical to today’s interdisciplinary approach to diagnosing and treating cardiovascular disease. MUSC will matriculate its first resident in 2009 and currently has one position open per year for their integrated program.

Fast-Track Programs

Residents in fast-track programs generally apply after their second year of general surgery residency, although at many institutions including Washington University and the Mayo Clinic, the application process is informal involving discussions between the general surgery and cardiothoracic surgery program directors. For a given institution’s fast-track program, only general surgery residents at that same institution are eligible. Residents who complete this track are eligible for both ABS and ABTS certification. In Dr. Joseph Dearani’s view (Mayo Program Director), this ability of program directors to assess the residents’ performance in the first 2 years of general surgery is a key advantage to fast-track programs compared to integrated programs. Some institutions, such as Washington University, expect fast-track residents to spend several years doing basic research after the resident’s second year of general surgery before entering the fast-track program. Once accepted into the fast-track program, the resident’s 4th year of general surgery is generally modified to contain more cardiothoracic training and the 12 months as chief resident for general surgery is split between the 4th and 5th year. At Washington University, the altered structure of the fast-track curriculum allows a 3-4 month away rotation that was not possible in the traditional cardiothoracic curriculum. Residents then complete 2 more years of cardiothoracic training at the same institution. This continuity between general surgery and cardiothoracic surgery is an additional advantage to the fast-track program, says current Mayo Clinic fast-track resident Dr. Stephen McKellar, as it allows for residents to continue research projects that were started during their general surgery training. According to Dr. Marc Moon (Washington University Program Director), the fast-track program provides the principle advantage of an additional year of cardiothoracic training over the traditional 2 year cardiothoracic surgery fellowship, which will result in better technically trained graduates. In Dr. Dearani’s view (Mayo Program Director) the fast-track program is an intermediate step to the integrated program. And, in fact, Mayo is currently developing its own integrated program.

Relative Advantages and Disadvantages of Integrated and Fast-Track Programs

Integrated programs allow both more focused, streamlined cardiothoracic training as well as training in fields adjunct to cardiothoracic surgery that are important to an interdisciplinary approach to cardiovascular disease. Integrated programs also allow for more training in new technologies such as robotics and minimally invasive approaches. While integrated programs provide training tailored to the career of the cardiothoracic surgeon, there are several drawbacks. These integrated programs remain experimental. While each institution’s program has the flexibility to alter the curriculum as different portions of the curriculum are found to be more or less beneficial, these programs do not yet have successful graduates to assure potential employers of the effectiveness of this training modality. As such, considerable attention will be paid to the early graduates of these programs to assess the success of this new integrated training approach. Another potential drawback to the integrated training approach is that medical students will need to decide on cardiothoracic surgery as a career by their fourth year of medical school instead of their fourth year of general surgery. While many specialties require such decisions of medical students, this will require an active effort to attract students early in medical school to the field of cardiothoracic surgery. Another drawback to the integrated training approach is missing the 5th year of general surgery, which is a year regarded by many as the key for the development of technical skills and clinical decision-making. Finally, some are concerned that the surgical maturity that comes with years of general surgery training will be lost.

The fast-track programs have several advantages relative to the integrated programs, including the fact that residents have more exposure to the different fields of surgery before deciding on cardiothoracic surgery (and conversely programs can assess residents’ performance in general surgery) and residents maintain the experience of the chief resident year. Potential drawbacks include that fast-track programs only choose from within their general surgery program and that early training includes fields largely not applicable to a cardiothoracic surgeon’s long-term career.

Qualities of Successful Applicants to Integrated and Fast-track Programs

Integrated and fast-track programs are looking for the same qualities that traditional cardiothoracic residencies are looking for in applicants including publications, test scores, letters of recommendation, and how an applicant will fit into the department. Of particular importance to these programs, especially the integrated programs, is dedication to and interest in cardiothoracic surgery. As far as what interested medical students can do to optimize their chances of getting into the new integrated programs, Dr. Robbins (Stanford Program Director), recommends that medical students do more than just their required clinical rotations by either spending time doing cardiothoracic-related research or focused time in cardiothoracic surgery rotations. It is also recommended that applicants to the integrated programs spend time in clinical rotations at the institutions to which they are applying.

Future Directions for Cardiothoracic Surgery Education

The debate over the future of cardiothoracic surgery education continues. Some expect that all programs in the country will become integrated, with fast-track programs an intermediary step, while others see the need for multiple pathways for cardiothoracic surgical training. The ABTS recently passed a proposal that comprehensive integrated cardiothoracic surgery training, beginning directly after medical school graduation, become the sole pathway leading to ABTS certification starting in 2020. This proposal does not mandate such a change, but rather, the ABTS encourages thorough discussion throughout the profession regarding the merits and challenges of such a change. The opinion of the Thoracic Surgery Directors’ Association will be particularly important, as this association has the responsibility of running the nation’s cardiothoracic surgery residencies. Then, taking into account the issues brought up in this nationwide discussion, the ABTS will make a final decision on instituting such a change sometime next year.

Were this proposal ultimately approved by ABTS, it would require cardiothoracic surgery programs to institute such an integrated program by 2013. Each institution’s program would need to be approved by the Residency Review Committee in Thoracic Surgery as well as their own institution’s Graduate Medical Education Department. Dr. Richard Feins, Chair of the ABTS, says that these programs will be individualized in nature, requiring certain core competencies, but allowing ample flexibility for each institution to custom-design their program. The ABTS has already been discussing ways in which residents who decide to pursue cardiothoracic surgery after completing several years of general surgery could still enter such integrated programs. Dr. Feins anticipates such residents receiving up to 2 years of credit upon entering an integrated program.

In Dr. Feins’ view, such changes are necessary given the increased breadth of knowledge and skill sets required by today’s cardiothoracic surgeons. Two years of cardiothoracic training are not enough, Dr. Feins said. Furthermore, such a focused, integrated approach is much more attractive to potential trainees. However, much is required to make such change successful, ranging from an active effort by the cardiothoracic surgical community to attract medical students to the specialty, cooperation from other surgical specialties in training integrated residents, as well as the logistical and financial challenges for institutions to acquire the additional residency positions necessary for an integrated program.

Acknowledgements

Special thanks to the many people who were interviewed for this article, including the Chair of the ABTS Dr. Richard Feins, cardiothoracic program directors Dr. Robert Robbins, Dr. Michael Acker, Dr. Fred Crawford, Dr. Joseph Dearani, and Dr. Marc Moon, and current integrated and fast-track program residents Dr. Clay Kaiser, Dr. Matthew Forrester, Dr. Katherine Harrington, Dr. Timothy Pirolli, and Dr. Stephen McKellar.

References

1. Crawford FA, Jr. Presidential address: Thoracic surgery education—Responding to a changing environment. J Thorac Cardiovasc Surg. 2003;126(5):1235-42
2. Pathways to Completing Thoracic Surgery Residency Education. RRC News Thoracic Surgery. Fall 2008;1.

Additional Resources

Articles on Changes in Cardiothoracic Surgery Training

1. Baumgartner WA. Cardiothoracic Surgery: A Specialty in Transition—Good to Great? Ann Thorac Surg. 2003;75:1685-92
2. Crawford FA, Jr. Presidential address: Thoracic surgery education—Responding to a changing environment. J Thorac Cardiovasc Surg. 2003;126(5):1235-42
3. Crawford FA, Jr., Thoracic Surgery Education—Past, Present, Future. Ann Thorac Surg. 2005;79:S2232-7
4. Kron I. Changes in Thoracic Surgery Training. Am Surg. 2007;73(2);155-156
5. Chitwood RW, Jr., Spray TL, Feins RH, Mack MJ. Mission Critical: Thoracic Surgery Education Reform. Ann Thorac Surg. 2008;86;1061-2

November/December AATS Newsletter’s article describing ABTS resolution

• http://www.aats.org/Association/Thoracic_Surgery_News.html

Websites for Integrated and Fast-Track programs

Integrated Programs

• Stanford: http://ctsurgery.stanford.edu/residencies/ctsurg.html
• Penn: http://www.uphs.upenn.edu/surgery/clin/ct/cardiothoracic_program.html
• MUSC: http://academicdepartments.musc.edu/surgery/divisions/cardiothoracic/residency /program.htm

Fast-Track Programs

(Note: only Washington University’s website specifically mentions the Fast-Track option)

• Washington University: http://www.cardiothoracicsurgery.wustl.edu/Teaching/Overview Fellowship.asp
• Mayo Clinic: http://www.mayo.edu/msgme/surg-cardiothoracic-rch.html
• Brigham and Women’s Hospital/Children’s Hospital Program:http://www.brighamandwomens.org/surged/Medical/Cardiothoracic.aspx
• Duke: http://cardio.surgery.duke.edu/modules/div_sgy_cardio_edu/index.php?id=1
• University of Rochester: http://www.urmc.rochester.edu/surgery/education/residencies-fellowships/residency-cardiothoracic.cfm
• University of Maryland: http://www.umm.edu/gme/prog_list.htm
• University of Virginia: http://www.healthsystem.virginia.edu/internet/surgery/res-thoracic.cfm

Publication Date: 6-May-2009