Factors affecting interest in cardiothoracic surgery: Survey of North American general surgery residents

Accreditation Council for Graduate Medical Education case log: general surgery resident thoracic surgery experience

BACKGROUND

General surgery resident training has changed dramatically over the past 2 decades, with likely impact on specialty exposure. We sought to assess trends in general surgery resident exposure to thoracic surgery using the Accreditation Council for Graduate Medical Education (ACGME) case logs over time.

METHODS

The ACGME case logs for graduating general surgery residents were reviewed from academic year (AY) 1989-1990 to 2011-2012 for defined thoracic surgery cases. Data were divided into 5 eras of training for comparison: I, AY89 to 93; II, AY93 to 98; III, AY98 to 03; IV, AY03 to 08; V, AY08 to 12. We analyzed quantity and types of cases per time period. Student t tests compared averages among the time periods with significance at a p values less than 0.05.

RESULTS

A total of 21,803,843 general surgery cases were reviewed over the 23-year period. Residents averaged 33.6 thoracic cases each in period I and 39.7 in period V. Thoracic cases accounted for nearly 4% of total cases performed annually (period I 3.7% [134,550 of 3,598,574]; period V 4.1% [167,957 of 4,077,939]). For the 3 most frequently performed procedures there was a statistically significant increase in thoracoscopic approach from period II to period V.

CONCLUSIONS

General surgery trainees today have the same volume of thoracic surgery exposure as their counterparts over the last 2 decades. This maintenance in caseload has occurred in spite of work-hour restrictions. However, general surgery graduates have a different thoracic surgery skill set at the end of their training, due to the predominance of minimally invasive techniques. Thoracic surgery educators should take into account these differences when training future cardiothoracic surgeons.

Physician assistant model for lung procurements: a paradigm worth considering

BACKGROUND

Thoracic procurements have traditionally been performed by surgical fellows or attending cardiothoracic surgeons. Donor lung procurement protocols are well established and fairly standardized; however, specific procurement training and judgment are essential to optimizing donor utilization. Although the predicted future deficits of cardiothoracic surgeons are based on a variety of analytic models and scenarios, it appears evident that there will not be a sufficient number of trained cardiothoracic surgeons over the next 2 decades. Over the past 5 years in our institution, lung procurements have been performed by a specifically trained physician assistant; as the lead donor surgeon. This model may serve as a cost effective, reproducible, and safe alternative to using surgical fellows and attending surgeons, assuring continuity, ongoing technical expertise, and teaching while addressing future workforce issues as related to transplant.

METHODS

This is a single institution review of 287 consecutive lung procurements performed by either a physician assistant or fellow over 5 years. This study was approved by the Institutional Review Board of Columbia University, which waived the need for informed consent (IRB#AAAL7107).

RESULTS

From 2008 to 2012, fellows served as senior surgeon in 90 cases (31.4%) versus 197 cases (68.6%) by the physician assistant, including 12 Donations after Cardiac Death and 6 reoperative donors. Injury rate was significantly lower for the physician assistant compared with the resident cohort (1 of 197 [0.5%] vs 22 of 90 [24%], respectively). Rates for pulmonary graft dysfunction grade 2 and 3 were found to be significantly lower in cases where the physician assistant served as senior surgeon (combined rates of 32.2% [29 of 90] vs 9.6% [19 of 197] in the physician assistant group) (p < 0.01).

CONCLUSIONS

Use of experienced physician assistants in donor lung procurements is a safe and viable alternative offering continuity of technical expertise and evaluation of lung allografts.

Characteristics in response rates for surveys administered to surgery residents

BACKGROUND

Surveys are important research tools that permit the accumulation of information from large samples that would otherwise be impractical to collect. Resident surveys have been used frequently to monitor the quality of postgraduate training. Low response rates threaten the utility of this research tool. The purpose of this study was to determine the standard response rate of surveys administered to surgery residents and identify characteristics associated with achieving greater response rates.

METHODS

A search of peer-reviewed literature published between September 2003 and June 2011 was performed with the use of PubMed with Medical Subject Headings: "internship and residency," "surgery," "data collection," and "questionnaires." For inclusion, articles must have described a survey given to active surgery residents within the United States. Surveys were evaluated based on the following criteria: population size, response rate, incentive use, follow-up use, survey format (online vs paper), and institution versus national.

RESULTS

Of 433 initial results, 47 met inclusion criteria with a mean response rate of 65.3%. Surveys administered in paper format had a greater response rate compared with those given electronically (mean 78.6% vs 36.4%, respectively, P < .001). Greatest mean response rates were seen for institutional surveys compared with those given nationally (83.1% vs 42% respectively, P < .001).

CONCLUSION

Our review demonstrated that paper surveys administered at the institutional level and during assemblies integrated into residents' schedules demonstrated enhanced response rates. The validity and generalizability of data collected through such surveys will improve as the aspects which dictate response rate are better understood and implemented.

Spouses of thoracic surgery applicants: changing demographics and motivations in a new generation

INTRODUCTION

Applications to thoracic residency have decreased. The causes are multifactorial, but include changing motivations such as lifestyle concerns. Thoracic residents (TRs) have been well studied, but no one has ever characterized the influence or motivations of their spouses. We sought to evaluate the demographics and interests of TR spouses.

METHODS

An electronic survey was sent to all TR applicants over 2 years at 2 training programs and to all current TRs in 2010. Recipients were asked to forward the survey to their spouses. Responses were analyzed globally and compared in subgroups.

RESULTS

Sixty-six surveys were completed and returned for a response rate of 19%. Among them, 86% of respondents were female, with 82% being married for a mean of 4.3 years. Fifty-nine percent of respondents had children and 64% were planning on having more children within 3 years. Hundred percent felt optimistic that they would be financially stable after training, but only 57% were optimistic about quality of life after training. Eighty-four percent felt that they had influence on the choice of training program. Almost 80% wanted more information on salary, housing, and access to faculty spouses. Quality of fellowship, geographic location, and proximity to family were the top 3 factors in choosing a program.

CONCLUSIONS

Nearly 90% of respondents reported they want to travel to more interviews, and nearly 90% of respondents reported having some to complete influence over which training program to attend. It is safe to presume, therefore, that applicant spouses are not only highly influential on TR applicants but also interested in greater inclusion in the interview process. The results show numerous demographic and characteristic trends which, if further validated by definitive studies, would be applicable to all post-surgery residency training programs and may help TR programs to be more competitive in attracting applicants and their families.

Projecting surgeon supply using a dynamic model

OBJECTIVE

To develop a projection model to forecast the head count and full-time equivalent supply of surgeons by age, sex, and specialty in the United States from 2009 to 2028.

SUMMARY BACKGROUND DATA

The search for the optimal number and specialty mix of surgeons to care for the United States population has taken on increased urgency under health care reform. Expanded insurance coverage and an aging population will increase demand for surgical and other medical services. Accurate forecasts of surgical service capacity are crucial to inform the federal government, training institutions, professional associations, and others charged with improving access to health care.

METHODS

The study uses a dynamic stock and flow model that simulates future changes in numbers and specialty type by factoring in changes in surgeon demographics and policy factors.

RESULTS

: Forecasts show that overall surgeon supply will decrease 18% during the period form 2009 to 2028 with declines in all specialties except colorectal, pediatric, neurological surgery, and vascular surgery. Model simulations suggest that none of the proposed changes to increase graduate medical education currently under consideration will be sufficient to offset declines.

CONCLUSIONS

The length of time it takes to train surgeons, the anticipated decrease in hours worked by surgeons in younger generations, and the potential decreases in graduate medical education funding suggest that there may be an insufficient surgeon workforce to meet population needs. Existing maldistribution patterns are likely to be exacerbated, leading to delayed or lost access to time-sensitive surgical procedures, particularly in rural areas.

Perceptions and expectations of cardiothoracic residents and attending surgeons

BACKGROUND

With our specialty going through a critical phase of re-evaluation and adaptation, our aim was to evaluate and compare the perceptions and expectations among residents and faculty regarding cardiothoracic training.

METHODS

A content-validated, 13-item survey was distributed electronically from August 14 to August 24, 2010 to 728 cardiothoracic surgery residents, recent program graduates (on or after June 2006), cardiothoracic surgery chairpersons, and program directors identified in the Cardiothoracic Surgery Network database.

RESULTS

The response rate was 34% (244 of 728). Of the respondents, 76% reported being "satisfied" or "very satisfied" with their program. Faculty willingness to teach in the operating room was ranked as the most valuable aspect of a training program, and strict adherence to the 80-h work week ranked as least valuable. Most respondents believed that a resident performing at least 75% of a case was acceptable for low-complexity procedures (92% of residents, 77% of attending physicians) and at least 25% for high-complexity procedures (91% of residents, 73% of attending physicians). However, residents wanted to perform more of the operations than the attending physicians considered necessary (P < 0.05). Finally, 63% of respondents (73% of residents, 56% of attending physicians) indicated that the increasing scrutiny of outcomes has adversely affected training. Other differences between the residents' and attending physicians' perceptions regarded the importance of participation in preoperative and postoperative care, what constitutes "scut work," and the value of auxiliary staff.

CONCLUSIONS

Reconciling residents' expectations with the realities of duty-hour restrictions and high-stakes procedures will require the development of novel educational approaches to improve resident learning.

Why choose cardiothoracic surgery as a career?

The future of cardiothoracic surgery faces a lofty challenge with the advancement of percutaneous technology and minimally invasive approaches. Coronary artery bypass grafting (CABG) surgery, once a lucrative operation and the driving force of our specialty, faces challenges with competitive stenting and poor reimbursements, contributing to a drop in applicants to our specialty that is further fueled by the negative information that members of other specialties impart to trainees. In the current era of explosive technological progress, the great diversity of our field should be viewed as a source of excitement, rather than confusion, for the upcoming generation. The ideal future cardiac surgeon must be a "surgeon-innovator," a reincarnation of the pioneering cardiac surgeons of the "golden age" of medicine. Equipped with the right skills, new graduates will land high-quality jobs that will help them to mature and excel. Mentorship is a key component at all stages of cardiothoracic training and career development. We review the main challenges facing our specialty--length of training, long hours, financial hardship, and uncertainty about the future, mentorship, and jobs--and we present individual perspectives from both residents and faculty members.