Two- versus Three-year Cardiothoracic Training Programs: Barking Up the Wrong Tree

Cardiothoracic surgery is undergoing a period of sweeping change.  Our specialty was born out of the surgical treatment of tuberculosis and reached a "tipping point" near the half-way mark of last century.  Technology and innovation evolved rapidly behind surgical pioneers.  It all started with pioneers like Blalock, Gibbon, Kirklin and Lillehei, who ushered in the new field of congenital cardiac surgery.  Later, other pioneers like Sabiston, Cooley and Debakey developed the field of vascular surgery including coronary revascularization.  Last, but not least, pioneers like Shumway and Barnhard introduced cardiac transplantation.  The surgical solutions created by these innovators, and many like them, filled the large vacuum created by the lack of treatment options for patients dying of both congenital and acquired cardiovascular disease. 

Over time, the sheer magnitude of acquired cardiovascular disease, particularly coronary artery disease, eclipsed other aspects of cardiothoracic surgery.  Most cardiothoracic surgeons today practice adult cardiovascular surgery, the most common operation being coronary artery bypass grafting (CABG).  For the past 20+ years, cardiothoracic surgery training programs have reflected the specialty's needs, or the huge demand for surgeons able to perform coronary revascularization.  This narrow focus has left some within the specialty feeling that other aspects of cardiothoracic surgery have been neglected¹.  Examples include the nonsurgical treatment of cardiovascular disease, such as percutaneous coronary intervention (PCI) and endoscopic treatment of aerodigestive diseases that have changed the practice of both cardiovascular and general thoracic surgery.  Leaders in our field have been innovating and are adapting.  As the numbers of CABG cases have decreased, other conditions and their treatments are gaining more attention at our national meetings. 

Subspecialty cardiothoracic surgery is upon us and areas like antiarrhythmia surgery, reoperative cardiac surgery, heart failure and assist devices, adult congenital, robotic and minimal access cardiac, lung and esophageal surgery are growing the specialty as a whole.   This led Dr. Baumgartner to proclaim in his presidential address "there has never been a more exciting time to be a cardiothoracic surgeon" ².  Those of us who have recently chosen this specialty, despite the many nay-sayers (from inside as well as outside the specialty), agree.  But two questions persist in the minds of younger surgeons, those who comprise the future of the specialty.  The first question is "as the specialty is grappling with these dramatic changes, has the training of cardiovascular surgeons kept pace?"  The second is, "will I be well trained?"

In 1965, during a time of fast-paced technological innovations which lead to great leaps in patient care, Drs. Eiseman and Spencer expressed one of the earliest concerns about the volume and outcome relationship which is well-studied today³.  In their editorial entitled The Occasional Open-Heart Surgeon, they questioned the proficiency and safety of surgical teams who performed less than 10 open-heart operations annually.  They wrote "…few would argue that a team can keep an optimum degree of training doing less that one case a month."  They concluded with a call for rigorous study of volume-outcome relationships in order to improve the care of patients undergoing cardiac surgery.  Has a volume-outcome relationship for cardiothoracic surgery training ever been explored?  Is there a relationship between case-volume during residency and patient-outcomes during practice?

With the duty-hour restrictions imposed on the field by the ACGME in 2003, the time-tested Halstead approach to training surgical residents is no longer an option and new, alternative methods for training are required.  The American Board of Thoracic Surgery (ABTS) has been responsive to these changes by waiving the requirement for American Board of Surgery certification and now offers three different pathways to obtain ABTS certification⁴.  Pathway One consists of the traditional 5 years of general surgery followed by an accredited 2 or 3 year thoracic surgery training program.  Pathway two consists of a joint general surgery/thoracic surgery training consisting of either 4 +3 or 5 + 2 years of general surgery and thoracic surgery training, respectively.  Pathway Three consists of an integrated cardiovascular training program consisting of 0 years of general surgery and 6 years of cardiovascular surgery.  No such integrated programs for general thoracic surgery exist, at present.  Some forward thinking cardiothoracic surgery training programs are incorporating these new pathways, and this is a good thing. 

While the quality of the final product of these new training pathways is still unknown, time will tell which, if any produces a superior product.  However, much of the current debate revolves not around these new pathways but involves a more incremental change regarding the length of the current 'accredited' thoracic surgery training programs.  At present, the ABTS requires a minimum of 24 months of training in thoracic surgery.  Many programs remain two years in duration but an increasing number of programs are increasing to three years.  Recent data have demonstrated the advantages of longer training as graduates from three-year training programs finish with more cases but also have a higher pass rate on the ABTS examination⁵. 

When is two years enough and when is it not?  Some argue that for residents wanting to do general thoracic surgery, two years following general surgery is sufficient as it is more an extension of general surgery (i.e. upper abdominal surgery) than is cardiovascular surgery.  Others, however, may argue that as the field of general thoracic surgery becomes more complex due to innovations in minimally invasive surgery (i.e. VATS lobectomy, minimal access esophagogastrectomy) and nonsurgical diagnostics and treatment of disease (endobronchial ultrasound (EBUS), photodynamic ablation of early esophageal cancers) makes three years more appealing in order to become proficient in these new fields.  Similarly, residents wanting to practice cardiovascular surgery should be knowledgeable and experienced in areas such as transplantation, robotic, ventricular assist devices, arrhythmia surgery, assist devices, reoperative cardiac surgery, mitral valve repair, and aortic surgery in addition to CABG and valve surgery.  Additionally, if one recognizes that during this same time period, residents still need to perform and become proficient in the other half of the specialty (cardiovascular or general thoracic surgery), three years sounds even more appealing, if not mandatory, to accomplish this goal.    

The ABTS case number requirements do not currently reflect the complexity of contemporary general thoracic and cardiovascular surgical practice.  The current categories are too broad and need to be subdivided into disease-specific competencies.  For example, there is no distinction between mitral valve repair or valve replacement.  Instead, both fall under the broad category of acquired valve disease.  Specific requirements are needed to ensure that residents have experience with the complex cases in the current era.  The need for more specific requirements is not unique to the cardiovascular side of the specialty, but is equally important for general thoracic surgeons considering the fields of VATS and robotic lobectomy, EBUS, and photodynamic therapy.  If all accredited training programs are not able to provide sufficient experience for residents in these new areas of thoracic surgery the effect could be regionalization of complex thoracic surgical operations.  This regionalization would not come because it is federally mandated, but because there will be a lack of surgeons proficient in complex procedures that will regionalize care.

These challenges have solutions.  Thoracic surgeons have always responded positively to change and ultimately will adapt to the ever-increasing complexity of thoracic surgery.  But will the training of future thoracic surgeons keep pace?  The debate about two-year versus three-year training programs is the wrong debate.  The debate should be about how we can get residents to do as many years as possible in thoracic surgery and its burgeoning subspecialties and fewer years in general surgery.  What are some possible solutions?  Residents need more thoracic surgery and less general surgery, particularly for those wanting to practice cardiovascular surgery.  If this paradigm does not work for both general thoracic as well as cardiovascular surgeons, perhaps it is time to split the accreditation and certification processes, still within the specialty but into more independent tracks, in order to focus more on the future than on the past.  It is apparent that one type of training program does not fit all anymore and encouraging multiple pathways as proposed by the ABTS is a good thing.  Perhaps the ABTS pathway one fulfills the needs of general thoracic surgeons and should be the only route for becoming a general thoracic surgeon.  I think the ultimate solution is to create several training options and let the residents choose which type of training program is most congruent with their career path.  Additionally, case requirements for ABTS certification should be focused to include more specific requirements to reflect the technology and complexity of contemporary thoracic surgery.  Training programs will need to adapt to meet the complexities of contemporary surgery in order to train competent cardiovascular and general thoracic surgeons.  Programs that can not offer training consistent with the specialty's complexity should close. 

Once again, we return to the "the occasional cardiac surgeon." If thoracic surgical training does not keep pace with these monumental changes pressing in on Thoracic Surgery, the specialty will be faced with a new type of "occasional cardiac surgeon," one who is trained only to perform the occasional, straightforward CABG or valve replacement and nothing else.  More time in cardiothoracic surgery, 3 years minimum, along with more rigorous case requirements for ABTS certification will create thoracic surgeons capable of performing operations of contemporary complexity which are needed at present and in the future.