Changes in Thoracic Surgery Experience During General Surgery Residency: A Review of the Case Logs From the Accreditation Council for Graduate Medical Education

Trends in Comprehensive Thoracic Case Experience Among General Surgery Residents in the Modern Integrated Cardiothoracic Residency Era: Review of Twenty Years of Resident Case Logs

BACKGROUND

Thoracic surgery training among general surgery residents in the United States is regulated by the Accreditation Council for Graduate Medical Education (ACGME) to ensure exposure to subspecialty fields during residency. Thoracic surgery training has changed over time with the placement of work hour restrictions, the emphasis on minimally invasive surgery, and increased subspecialization of training like integrated six-year cardiothoracic surgery programs. We aim to investigate how these changes over the past twenty years have affected thoracic surgery training among general surgery residents.

METHODS

ACGME general surgery resident case logs from 1999 to 2019 were reviewed. Data included exposure to the thorax via thoracic, cardiac, vascular, pediatric, trauma, and alimentary tract procedures. Cases from the above categories were consolidated to determine the comprehensive experience. Descriptive statistics were performed over four 5-year Eras (Era 1:1999-2004, Era 2: 2004-2009, Era 3: 2009-2014, Era 4: 2014-2019).

RESULTS

Between Era 1 and Era 4, there was an increase in thoracic surgery experience (37.6 ± 1.03 vs 39.3 ± .64; P = .006). The mean total thoracic experience for thoracoscopic, open, and cardiac procedures was 12.89 ± 3.76, 20.09 ± 2.33, and 4.98 ± 1.28, respectively. There was a difference between Era 1 and Era 4 in thoracoscopic (8.78 ± .961 vs 17.18 ± .75; P < .001) and open thoracic experience (22 ± .97 vs 17.06 ± .88; P < .001), and a decrease in thoracic trauma procedures (3.7 ± .06 vs 3.2 ± .32; P = .03).

DISCUSSION

Over twenty years there has been a similar, to slight increase in thoracic surgery exposure among general surgery residents. The changes seen in thoracic surgery training reflect the overall movement of surgery towards minimally invasive surgery.

Cardiac Surgery Exposure in General Surgery Residency-A Survey of General Surgery Residency Program Directors

BACKGROUND

Little is known regarding how much exposure general surgery residents have to cardiac surgery, despite cardiothoracic (CT) surgery being an offered postresidency fellowship and career. Exposure to a subspecialty is important in shaping residents' interests and career decisions.

METHODS

A survey was sent to all general surgery program directors via the Association of Program Directors in Surgery examining cardiac surgery exposure during training. The survey examined the presence of operative rotations in cardiac surgery and cardiac critical care, portions of cases residents were permitted to perform, cardiac surgery mentorship and education, and perceived biases in applying to cardiac surgery. Differences between programs with and without cardiothoracic training programs were analyzed.

RESULTS

In total, 44% (102/230) of program directors responded to the survey. Residents were involved in operative cardiac and cardiac ICU rotations in 61 programs (69.8%) and 39 programs (38.2%), respectively. Twenty programs (19.6%) had a dedicated cardiothoracic surgery training program and these programs had significantly more graduates who aspired to be cardiac surgeons (M = 2.75, SD = 2.47) compared to hospitals with no CT programs (M = 1.43, SD = 1.41; p = 0.031). 35.3% of program directors reported resident concern over family life.

CONCLUSIONS

There is a notable heterogeneity in general surgery resident exposure to cardiac surgery, cardiac ICU, and cardiac surgery mentorship. Increased exposure, mentorship and mitigating resident concern over the impact of social factors on cardiac surgical careers should be key areas of focus to ensure continued encouragement of future trainees and surgeons.

Clarifying the Role of the Modern General Surgeon: The Effect of Specialization on Inpatient Practice Patterns in General Surgery

OBJECTIVE

The growing concentration of fellowship-trained and integrated residency-trained subspecialty surgeons has encroached on the breadth and volume of a so-called "true" general surgery practice, leaving the role of new general surgeons in flux. We aimed to describe the surgical practice of new general surgeons with and without subspecialty fellowship training.

DESIGN

In this retrospective cohort study, state discharge data was linked to American Medical Association Masterfile and American Hospital Association annual survey data. New-to-practice general surgeons with and without subspecialty board-certification in colorectal surgery (CRS) or cardiothoracic surgery (CTS) were identified in 2008, and followed over 10 years. Surgeon overall inpatient case volume, colorectal resection case volume, and thoracic lobectomy case volume were compared between surgeons with and without related subspecialty training.

SETTING

NY and FL (2008-2017).

PARTICIPANTS

The study population included 276 new-to-practice surgeons with mean age of 36.9 years. New-to-practice surgeons were defined as those with zero to three years of experience in 2008.

RESULTS

Of all surgeons, 11.2% were subspecialty board-certified in CRS and 11.6% were subspecialty board-certified in CTS. Board-certified CRS surgeons performed more colorectal resections than the non-CRS general surgeons each year (p-value <0.001 for all). Overall, non-CRS general surgeons performed 60.7% of all colorectal resections. Board-certified CTS surgeons performed more thoracic lobectomies than non-CTS surgeons each year. Non-CTS surgeons performed 1.1% of all thoracic lobectomies.

CONCLUSIONS

On average, new subspecialty surgeons perform significantly more specialty operations than non-subspecialty new general surgeons. However, as a group, new non-colorectal general surgeons perform the majority of colorectal resections. In contrast, new non-cardiothoracic general surgeons perform less than two percent of the thoracic lobectomies. This may have implications for a shift in the training paradigm going forward.

A needs assessment of Canadian general surgery postgraduate trauma training

BACKGROUND

Clinical exposure to operative trauma cases for general surgery residents has decreased over recent decades. However, trainees are still expected to demonstrate competency in trauma care and injury management.

METHODS

A prospective survey based on preliminary qualitative analysis and a trauma education conceptual framework was distributed to general surgery educators, trauma surgeons, and general surgery residents across the country. Participants were asked to describe their trauma training experience, the educational resources available at their training programs, and their level of support for potential curriculum components.

RESULTS

45% (31/69) of educators and 14% (58/405) of trainees responded to the survey. Perceived deficiencies were identified in the operative management of thoracic (educators 13%, trainees 28%), mediastinal (3%, 14%), neck (16%, 33%), and vascular (26%, 47%) injuries. Additional educational deficiencies were also identified in the domains of trauma systems and epidemiology, research and quality improvement, and injury prevention. Educators identified more inadequacies in training than trainees. Both groups supported participation in radiology (77%, 85%) and guideline (74%, 90%) reviews, journal clubs (84%, 81%), education rounds (90%, 88%), leading trauma resuscitations (94%, 98%), and trauma resuscitation simulations (90%, 95%) as valuable educational initiatives.

CONCLUSIONS

Trauma training in Canada is currently perceived to be inadequate to support resident education. The development and implementation of competency-based curricular components will be essential to address the identified deficiencies. This data will be used to inform the development of a national trauma training curriculum and initiatives to enhance resident education.

Trends of core versus subspecialty operative procedures completed in general surgery residency training programs

INTRODUCTION

General surgery residency involves performing subspecialty procedures in addition to the core general procedures. However, the proportion of core general surgery versus subspecialty procedures during training is variable and its temporal changes are unknown. The goal of our study was to assess the current trends in core general surgery and subspecialty procedure distributions during general surgery residency training.

METHODS

Data were collected from the ACGME core general surgery national resident available report case logs from 2007 to 2019. Descriptive and time series analyses were used to compare proportions of average procedures performed per resident in the core general surgery category versus the subspecialty category. F-tests were conducted to show whether the slopes of the trend lines were significantly non-zero.

RESULTS

The mean of total procedures completed for major credit by the average general surgery resident increased from 910.1 (SD=30.31) in 2007 to 1070.5 (SD=37.59) in 2019. Over that same period, the number of general, cardiothoracic, plastic and urology surgery procedures increased by 24.9%, 9.8%, 76.6% and 19.3%, respectively. Conversely, vascular and paediatric surgery procedures decreased by 7.6% and 30.7%, respectively. The neurological surgery procedures remain stable at 1.1 procedures per resident per year. A significant positive correlation in the trend reflecting total (p<0.0001), general (p<0.0001) and plastic (p<0.0016) surgery procedures and the negative correlation in the trend lines for vascular (p<0.0006) and paediatric (p<0.0001) surgery procedures were also noted.

CONCLUSIONS

Trends in overall surgical case volume performed by general surgery residents over the last 12 years have shown a steady increase in operative training opportunity despite the increasing number of subspecialty training programmes and fellowships. Further research to identify areas for improvement and to study the diversity of operative procedures, and their outcomes is warranted in the years to come.

Post Procedural Cognitive Load Measurement with Immediate Feedback to Guide Curriculum Development

BACKGROUND

Methods to assess competency in cardiothoracic training are essential. Here, we report a system that allows us to better assess competency from the perspective of both the trainee and educator. We hypothesized that post-procedural cognitive burden measurement (by the trainee) with immediate feedback (from educator) could aid in identifying barriers to the acquisition of skills and knowledge so that training curricula can be individualized.

METHODS

The NASA-TLX (National Aeronautics and Space Administration Task Load Index), a validated instrument to measure cognitive load, was administered with an online platform following bronchoscopy, esophagogastroduodenoscopy (EGD), and video-assisted thoracoscopic surgery (VATS) for 11 residents. Immediate post-procedure feedback and standardized debriefing occurred for each procedure.

RESULTS

Mean NASA-TLX scores were highest (indicating greater cognitive load) for EGD and VATS (p<0.001). When comparing sub-scale measures, "mental demand" was significantly higher for VATS (p=0.026) compared to the other procedures, whereas "physical demand" was highest for EGD (p=0.018). Self-reported "frustration" was similar for all case types (p=0.247). Cognitive burden decreased with a greater number of procedures for bronchoscopy (p=0.027). Significant improvement was noted by the trainee at the end of the rotation in self-assessed procedural competency and preparedness for thoracic board topics (all p<0.05). Post-procedure feedback by the attending surgeon correlated with more frequent completion of self-evaluations by the residents.

CONCLUSIONS

Longitudinal assessment of cognitive load in combination with post-procedural feedback identified barriers to skill acquisition for both residents and educators. This information allows for individualized rotation development as a step towards a competency-based curriculum.

Recent Trends in Cardiothoracic Surgery Training: Data from the National Resident Matching Program

OBJECTIVE

In 2008, integrated thoracic residency programs (IP) for cardiothoracic (CT) training were created in response to a decline in CT trainees. However, few studies have reported on trends in the CT training pathway since the inception of IPs. This manuscript examines the current trends related to the overall number of surgical trainees entering CT surgery training following the introduction of IPs into the National Resident Match Program (NRMP).

DESIGN

Main and specialty match data were gathered from NRMP annual reports between 2008 and 2018. Descriptive statistics were used to analyze program size, applications, and filled and unfilled positions for IPs and traditional CT residency programs. Pearson's correlation coefficient was used to determine associations between program variables.

SETTING

NRMP main and specialty match in 2008 to 2018.

PARTICIPANTS

Participants of the NRMP main and specialty match in 2008 to 2018.

RESULTS

IPs increased from 2 programs offering 3 positions in 2008 to 28 programs offering 36 positions in 2018. However, during the same time period, the number of available traditional CT residency positions have decreased by 29% (130 to 92). As the number of IPs increased, there was a significant decrease in the number of traditional CT residency positions (ρ = -0.95, p < 0.001). Although, the overall number of CT residency programs (traditional and IP) remained largely unchanged, the proportion of filled CT residency positions increased from 67.7% in 2008 up to 97.7% in 2018.

CONCLUSION

The IP training format has shown success in increasing the number of trainees entering into CT training programs. Consideration should be given to increasing the number of IP positions or increase interest in CT among general surgery residents to increase the number of CT surgery trainees with the goal of increasing the size of the future CT workforce.

Impact of Integrated Thoracic Residency on General Surgery Residents' Thoracic Operative Volume

BACKGROUND

Integrated thoracic surgery (I-6) programs have become popular over traditional general surgery (GS) pathways since their inception in 2007. However the effect of I-6 programs on GS resident training remains unknown. The purpose of this study was to evaluate the effect of I-6 programs on the thoracic operative experience of co-located GS residents.

METHODS

Thoracic surgery cases recorded by residents in GS programs co-located with I-6 programs until 2019 were analyzed. Cases were reviewed 5 years before (TSR-5) through 5 years after (TSR-5) the matriculation of the first thoracic resident in the co-located I-6 program. To contextualize the overall trends in the field Accreditation Council for Graduate Medical Education GS resident case logs from 1990 to 2018 were analyzed and total thoracic surgery cases recorded. Statistical analysis was performed with linear regression.

RESULTS

Residents in 19 GS programs with co-located I-6 programs showed an increase in total thoracic cases from 3710 to 4451 (Δ/year of +85.05 cases a year; P = .03) balanced by an increase in GS residents from 107 to 126 (Δ/year of +1.45; P = .01) with no significant overall change in the median thoracic operative case volume (31.00 at both thoracic residency before and after 5 years). Nationally from 1990 to 2018 there was no change in the total thoracic operative experience for GS graduates.

CONCLUSIONS

The introduction of I-6 programs did not negatively impact thoracic operative experience for residents in co-located GS programs. Adequate training of both I-6 and GS residents at the same institution is feasible.

Self-Appraised Readiness of Senior and Graduating General Surgery Residents to Perform Thoracic Surgery

OBJECTIVE

General surgeons perform up to 50% of noncardiac thoracic surgery (TS). Although data show consistent TS case volume during general surgery (GS) residency it is unknown whether this operative trend will persist given potentially limited subspecialty exposure. We sought to determine if certain aspects of residency programs and resident characteristics were associated with trainees' perceived comfort in performing certain basic TS procedures.

DESIGN

An anonymous survey was distributed to GS residents regarding program characteristics, presence of a TS residency, and intent to pursue thoracic surgical training, and estimated case volumes of individual procedures. Comfort levels for performing video-assisted thoracoscopic surgical (VATS) procedures, open lobectomy, elective thoracotomy, and sternotomy were attained through a 5-point Likert-type scale.

SETTING

This survey was administered at 50 training programs with responses recorded via an online form.

PARTICIPANTS

Fourth- and fifth-year GS residents in the United States.

RESULTS

Of 272 respondents 58% were fourth-year residents, 62% of residents trained at university-affiliated programs, and 64% reported a TS residency program at their institution and 16% stated intent to pursue TS. Fifth-year residents performed significantly more cases than fourth-year residents despite no difference in median comfort levels. Residents intending to pursue TS performed significantly more cases and were more comfortable performing a thoracotomy, sternotomy, VATS wedge resection/biopsy, and VATS decortication/pleurodesis (p = 0.044, <0.001, 0.045, 0.025). No characteristics were associated with comfort performing a lobectomy via thoracoscopic or open (thoracotomy) approaches.

CONCLUSION

Most senior or graduating GS residents state they are comfortable performing certain thoracic procedures with those pursuing additional thoracic surgical training more comfortable overall. No characteristics were associated with comfort performing a lobectomy. These findings may advise residency curriculum design to ensure continued thoracic surgical exposure and recommend against non-fellowship trained surgeons performing a pulmonary lobectomy.

Video-assisted thoracic lobectomy for lung cancer in Italy: the ‘VATS Group’ Project

As part of the third Mediterranean Symposium in Thoracic Surgical Oncology, we introduce the Italian VATS Group ( http://vatsgroup.org/sito/index.php ). This national collaborative initiative was established in 2013 and started to recruit patients in January 2014; as of July 2016, 3680 patients have been enrolled in the database. Three different video-assisted thoracic surgery approaches have been predominantly used by Italian thoracic surgery centers, 71% of them preferentially adopting a multi-portal approach, with a 20% recorded morbidity. The majority of the cases were stage I adenocarcinomas of the lung. Conversion to open surgery occurred in 9% of the cases. The study suggests video-assisted thoracic surgery lobectomy as a ‘gold standard’ for the surgical treatment of early-stage lung cancer in Italy.