Identifying areas of weakness in thoracic surgery residency training: a comparison of the perceptions of residents and program directors

OBJECTIVE

To identify core thoracic surgery procedures that require increased emphasis during thoracic surgery residency for residents to achieve operative independence and to compare the perspectives of residents and program directors in this regard.

METHODS

A modified Delphi process was used to create a survey that was distributed electronically to all Canadian thoracic surgery residents (12) and program directors (8) addressing the residents' ability to perform 19 core thoracic surgery procedures independently after the completion of residency. Residents were also questioned about the adequacy of their operative exposure to these 19 procedures during their residency training. A descriptive summary including calculations of frequencies and proportions was conducted. The perceptions of the 2 groups were then compared using the Fisher exact test employing a Bonferroni correction. The relationship between residents' operative exposure and their perceived operative ability was explored in the same fashion.

RESULTS

The response rate was 100% for residents and program directors. No statistical differences were found between residents' and program directors' perceptions of residents' ability to perform the 19 core procedures independently. Both groups identified lung transplantation, first rib resection, and extrapleural pneumonectomy as procedures for which residents were not adequately prepared to perform independently. Residents' subjective ratings of operative exposure were in good agreement with their reported operative ability for 13 of 19 procedures.

CONCLUSION

This study provides new insight into the perceptions of thoracic surgery residents and their program directors regarding operative ability. This study points to good agreement between residents and program directors regarding residents' surgical capabilities. This study provides information regarding potential weaknesses in thoracic surgery training, which may warrant an examination of the curricula of existing programs as well as a reconsideration of what the scope of practice of a general thoracic surgeon should entail.

Clean technique for prolonged nonsurvival cardiothoracic surgery in swine (Sus scrofa)

Laboratory animal regulations provide little guidance regarding duration of nonsurvival surgery requiring aseptic technique. We hypothesized that swine would experience no sepsis during nonsurvival cardiothoracic surgery accomplished by using clean technique and lasting 8 h or less. Incision sites of 5 male farm pigs (Sus scrofa) were shaved and then cleaned with alcohol and povidone-iodine. The surgeon wore sterile gloves, clean scrubs, and hair bonnet; assistants wore clean scrubs and nonsterile gloves; most instruments were autoclaved. A median sternotomy incision was used for thoracic cavity exposure, and the skull was exposed to allow induction of brain death. Heart rate, body temperature, and blood samples were obtained before surgery (0 h; baseline) and at 2, 4, 5 or 6, and 7 or 8 h thereafter. Statistical analysis by t-tests showed that heart rate was unchanged and body temperature increased after the 0-h (baseline) time point. Aerobic blood cultures were negative except for 2 samples that were positive for coagulase-negative Staphylococcus spp. at 4 h. RBC, Hgb, and Hct levels were decreased at 2 and 4 h, but WBC and platelets were unchanged. Other alterations included decreased glucose (at 7 or 8 h), increased BUN (at 5 or 6 h and 7 or 8 h) and creatinine (at 5 or 6 h), decreased Na(+) and Ca and increased K(+) (most time points), decreased total protein and albumin (most time points), and decreased globulin (at 7 or 8 h). Liver enzymes and bilirubin typically were unchanged, and cholesterol consistently was decreased. Together our results indicate a lack of sepsis for 8 h or less in pigs undergoing cardiothoracic surgery by using clean technique. These findings provide new and specific data regarding the use of aseptic technique during prolonged nonsurvival surgeries.

The American Association for Thoracic Surgery guidelines for lung cancer screening using low-dose computed tomography scans for lung cancer survivors and other high-risk groups

OBJECTIVE

Lung cancer is the leading cause of cancer death in North America. Low-dose computed tomography screening can reduce lung cancer-specific mortality by 20%.

METHOD

The American Association for Thoracic Surgery created a multispecialty task force to create screening guidelines for groups at high risk of developing lung cancer and survivors of previous lung cancer.

RESULTS

The American Association for Thoracic Surgery guidelines call for annual lung cancer screening with low-dose computed tomography screening for North Americans from age 55 to 79 years with a 30 pack-year history of smoking. Long-term lung cancer survivors should have annual low-dose computed tomography to detect second primary lung cancer until the age of 79 years. Annual low-dose computed tomography lung cancer screening should be offered starting at age 50 years with a 20 pack-year history if there is an additional cumulative risk of developing lung cancer of 5% or greater over the following 5 years. Lung cancer screening requires participation by a subspecialty-qualified team. The American Association for Thoracic Surgery will continue engagement with other specialty societies to refine future screening guidelines.

CONCLUSIONS

The American Association for Thoracic Surgery provides specific guidelines for lung cancer screening in North America.

Do new thoracic surgeons feel ready to operate? Self-reported comfort level of thoracic surgery trainees and junior thoracic surgeons with core thoracic surgery procedures

OBJECTIVE

To evaluate and compare self-reported surgical experience and comfort levels of Canadian thoracic surgery trainees and junior thoracic surgeons (<5 years in practice) with respect to core thoracic surgery procedures.

METHODS

A modified Delphi process was used to create a survey that was distributed electronically to all Canadian thoracic surgery residents and newly graduated thoracic surgeons. A descriptive summary, including calculation of frequencies, means, proportions, and standard deviations was conducted. Associations between reported experience and comfort level for residents and surgeons were explored separately using the Pearson product moment correlation. The differences between resident and junior surgeons' rating of experience and comfort for each procedure were explored using Fisher exact tests.

RESULTS

The response rates were 50% for residents and 85% for staff. Adequate or better experience was reported by residents for 9 of 18 core thoracic surgical procedures and by staff for 10 of 18 procedures. A significant difference in self-reported experience level was found between groups for only 1 of 18 procedures. Staff reported that they would confidently perform 7 of 18 procedures independently at the end of their training. The mean resident response did not reach this level of comfort for any of the 18 procedures. Eight of 16 staff had completed extra training, primarily for personal interest, whereas 4 of 6 residents were planning on further training because of job market factors.

DISCUSSION

The results of this study help to characterize the comfort levels of thoracic trainees and new attending thoracic surgeons with core thoracic procedures and might assist training programs in identifying and improving areas of weakness.

Has Microsoft left behind risk modeling in cardiac and thoracic surgery?

This concept paper examines a number of key areas central to quality and risk assessment in cardiac surgery. The effect of surgeon and institutional factors with regard to outcomes in cardiac surgery is utilized to demonstrate the need to sub analyze cardiac surgeons performance in a more sophisticated manner than just operation type and patient risk factors, as in current risk models. By utilizing the mathematical/engineering concept of Fourier analysis in the breakdown of cardiac surgical results the effects of each of the core components that makes up the care package of a patient's experiences are examined. The core components examined include: institutional, regional, patient, and surgeon effects. The limitations of current additive (Parsonnet, Euroscore) and logistic (Euroscore, SouthernThoracic Society) regression risk analysis techniques are discussed. The inadequacy of current modeling techniques is demonstrated via the use of known medical formula for calculating flow in the internal mammary artery and the calculation of blood pressure. By examining the fundamental limitations of current risk analysis techniques a new technique is proposed that embraces modern software computer technology via the use of structured query language.

Pitfalls in penetrating thoracic trauma (lessons we learned the hard way...)

The majority of patients with penetrating thoracic trauma are managed non-operatively. Those requiring surgery usually go to theater with physiological instability. The critical condition of these patients coupled with the rarity of penetrating thoracic trauma in most European countries makes their surgical management challenging for the occasional trauma surgeon, who is usually trained as a general surgeon. Most general surgeons have a general knowledge of basic cardiothoracic operative surgery, knowledge originating from their training years and possibly enhanced by reading operative surgery textbooks. Unfortunately, the details included in most of these books are not extensive enough to provide him with enough armamentaria to tackle the difficult case. In this anatomical region, their operative dexterity and knowledge cannot be compared to that of their cardiothoracic colleagues, something that is taken for granted in their cardiothoracic trauma textbooks. Techniques that are considered basic and easy by the cardiothoracic surgeons can be unfamiliar and difficult to general surgeons. Knowing the danger points and the pitfalls that will be encountered in cardiothoracic trauma surgery will help them to avoid intraoperative errors and improve patient outcome. The purpose of this manuscript is to highlight the commonly encountered pitfalls by trauma surgeons operating on penetrating trauma to the chest.

NHS goes to the PROMS

Sir Bruce Keogh has been credited for encouraging cardiac surgeons to publish their results. Now, as the medical director of the NHS, he’s turning his attention to other specialties. Nick Timmins investigates

Standards for Thoracic Surgical Oncology in a Single-Payer Healthcare System

Through systematic literature review and a consensus-based approach from an expert panel, standards on the organization for delivering thoracic cancer surgery in a single-payer healthcare environment were developed. Thirty-two studies and six organizational reports were identified. Results from 32 studies showed a trend toward higher volumes and improved patient outcomes, and six consensus reports provided recommendations on thoracic care standards. Thoracic surgical oncology standards in a single-payer healthcare system were developed. The benefits associated with the implementation of thoracic cancer surgery standards should result in increased regionalization of care, improved processes of care, and better patient outcomes.

Estimating the potential impact of regionalizing health care delivery based on volume standards versus risk-adjusted mortality rate

OBJECTIVE

To examine whether basing regionalization on risk-adjusted mortality would lead to better population outcomes than basing regionalization on procedure volume.

DATA SOURCE

We used secondary data from the California State Inpatient Database obtained from the Healthcare Costs and Utilization Project.

STUDY DESIGN

A population-based retrospective cohort study of 243 thousand patients who underwent either abdominal aortic aneurysm surgery, coronary artery bypass surgery or coronary angioplasty between 1998 and 2000 in California. Four regionalization strategies were compared: (i) selective referral to high-quality hospitals; (ii) selective referral to high-volume hospitals; (iii) selective avoidance of low-quality hospitals; (iv) selective avoidance of low-volume hospitals.

PRINCIPAL FINDINGS

Selective referral to high volume centers would be only moderately effective (2-20% relative reduction in mortality) and extremely disruptive (70-99% reduction in the number of hospitals treating these conditions). Selective referral to high quality centers was estimated to result in dramatic reduction in mortality (50%) but would also be highly disruptive with greater than 80% of the patients re-directed to high quality centers. Selective avoidance of low volume hospitals would not improve mortality, whereas selective avoidance of low quality hospitals was estimated to result in a small improvement in overall mortality (2-6%) while causing relatively minor disruptions in patient referral patterns.

CONCLUSION

Efforts to use volume standards as the basis for evidence-based hospital referrals should be re-evaluated by all stake-holders before promoting further efforts to regionalize health care delivery using volume cutoffs.

[Evaluation of thoracic surgical practice. The impact of specialisation and the effect of volume on the results of cancer treatment: resectability, post-operative mortality, and long-term survival]

INTRODUCTION AND METHODS

The impact of the volume of activity and the specialisation of the surgeon and the hospital on the quality of health care for patients with non-small cell lung cancer (NSCLC) was evaluated from the publications over the last 20 years.

RESULTS

The statistics, based mainly on administrative data, identified a significant decrease in post operative mortality (5 out of 7 studies) and improved long-term survival (2 out of 3 studies) in establishments undertaking large numbers of lung resections. The threshold for defining high volume groups varied from study to study (from 28 to 128 procedures per year). The same tendency was seen among the surgeons where specialisation in thoracic surgery led to higher levels of resectability and parenchymal preservation.

CONCLUSIONS

These results should be interpreted with caution on account of the nature of the data and the methodology employed. A certification of referral centres, validated by the French Thoracic and Cardiovascular Surgical Society, based on the training, level of activity in cancer surgery, and the infrastructure of the hospital should lead to a more even standard of care for patients with NSCLC.

[The connection between hospital volume and outcome in thorax surgery]

A review of current literature with respect to a possible correlation among hospital volume, caseload and outcome of thoracic and cardiovascular surgery supports quite convincingly the theory that, from a probability point of view, the combination of high-volume hospitals with high-volume surgeons produces the best results. During the last decade, thoracic and cardiovascular surgery has to a certain degree been centralized in Denmark, reducing the number of public centres to the five university hospitals. None of these centres is low-volume, and two are high-volume hospitals.