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Ann Thorac Surg 1997;64:1212-1215
© 1997 The Society of Thoracic Surgeons

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Report

Thoracic Surgery Directors Association Report 1995–1997

Division of Cardiothoracic Surgery, University of California Davis Health System, Sacramento, California

	Introduction

Top Footnotes Introduction The Curriculum Implementation... TSDA Communication With Related... The Future References

 
The Thoracic Surgery Directors Association (TSDA) consists of the directors of residencies (programs) in thoracic surgery that are approved by the Accreditation Council for Graduate Medical Education (ACGME) of the American Medical Association. Each program director has the option of selecting an additional faculty member for associate membership in the TSDA. Just after the completion of my privilege of serving 2 years as President of the TSDA, the purpose of this report is to acknowledge the excellent work of the TSDA Executive Committee and the enthusiasm of the membership and to summarize the activities of the TSDA from April 1995 until May 1997.

The TSDA regularly solicits the viewpoints of residents in thoracic surgery whose consensus about the selection process was that it has been suboptimum to be asked to make priority choices for residencies in thoracic surgery 2 years in advance. Accordingly, the TSDA skipped the 1996 National Resident Matching Plan process. The results of the match for positions to start in 1998 were announced in June 1997.

The annual TSDA Award for Excellence in Research is made during the meeting of The Society of Thoracic Surgeons. The 1995 award was given to Sanjiv Gandhi, who worked with James L. Cox [1]; the 1996 award was given to Edward Chen, who worked in the laboratory of Walter G. Wolfe [2].

In April 1995, the TSDA decided that there would be special emphasis on improving implementation methods for the comprehensive Thoracic Surgery Curriculum [3]. This publication had been developed by the directors, led by Stanton P. Nolan and Robert Salley, during the immediate preceding presidency of Gordon F. Murray. It was also agreed that there would be a TSDA Retreat for the purpose of discussing two major issues: (1) the preparatory or prerequisite education of thoracic surgery residents and (2) the adaptation of thoracic surgery residences to ongoing decreases in the funding of health care and postgraduate education.

Funding for the retreat was from The American Association for Thoracic Surgery, The American Board of Thoracic Surgery (ABTS), The Coordinating Committee for Continual Education in Thoracic Surgery, The Foundation for Research and Education in Thoracic Surgery, The Society of Thoracic Surgeons, and the TSDA.

The participants in the September 6, 1996, TSDA Retreat in Chicago were 91 Program Directors, and 53 associate members, including 12 Canadians. Two residents participated as invited guests. The following is a summary of the full Report of the Thoracic Surgery Directors Association Retreat, 1996, which was approved by the TSDA on February 1, 1997 [4].

A Keynote Address was given by Jordan J. Cohen, the President of the American Association of Medical Colleges, who spoke about current issues in medical education, including the fiscal constraints that threaten quality. He advised the TSDA to adhere to educational goals and not to compromise quality because of financial considerations. Additionally, David J. Smith, Jr, the Secretary of the Association of Academic Chairmen in Plastic Surgery, reviewed a decade of transition to an "integrated" Surgery/Plastic Surgery Curriculum. Smith described how divergent opinions about the need for American Board of Surgery (ABS) certification were addressed within the various plastic surgery organizations. The result was that American Board of Plastic Surgery changed from requiring ABS certification to making ABS certification optional. The authority to make this change lay with the Board and the ACGME. However, Smith emphasized that the Association of Academic Chairmen in Plastic Surgery was the forum that ultimately led to the "integrated" curriculum and to the decision that ABS certification would become optional for plastic surgeons.

Six topics were each considered by a working group toward the goal of bringing the group reports together for plenary sessions that included all the participants:

• Funding of thoracic surgery residencies
  
• The prerequisite curriculum
  
• Thoracic surgery–general surgery relations
  
• Thoracic surgery subspecialty education ("tracking")
  
• American Board of Surgery certification
  
• Future of the TSDA in thoracic surgery education
  

Closely related, but nonetheless discrete topics were separated from one another. For example, consideration of the "ideal" prerequisite curriculum in general surgery was separated from consideration of the need for certification by ABS, and each of these topics was discussed separately from the relations between the specialties of general surgery and thoracic surgery.

Funding of thoracic surgery education was considered by 13 participants led by Gordon Olinger, who is now the President-elect of the TSDA. The group agreed that funding issues should not serve as the basis for change. Among the strategic directions identified were the following two: (1) Funding mechanisms that will be capable of adapting to restrictions of current sources of support need to be developed. (2) Integrated thoracic surgery residencies that would give thoracic surgery directors longer direct responsibility for thoracic surgery education should be explored. Among the action plans proposed were the following two: (1) An "all payor" mechanism for funding thoracic surgery education should be actively supported. (2) A task force for the development of pilot integrated residencies in thoracic surgery should be formed by the TSDA.

The prerequisite curriculum was considered by a group of 19 people led by Douglas Mathisen. They identified 8 mandatory categories, 6 desired categories, and 4 optional areas of education:

• Eight mandatory categories of knowledge and skill
  • Critical care
    
  • Trauma care
    
  • Emergency triage
    
  • Gastrointestinal surgery
    
  • Vascular surgery
    
  • Surgical oncology
    
  • Pediatric surgery
    
  • Thoracic surgery
    
  
  
• Six desired categories of knowledge and skill
  • Anesthesiology
    
  • Head and neck surgery
    
  • Pulmonary medicine
    
  • Transplantation
    
  • Reconstructive surgery
    
  • Cardiovascular medicine
    
  
  
• Four optional categories of knowledge and skill
  • Chest pathology
    
  • Spine surgery
    
  • Radiologic imaging
    
  • Laboratory research
    
  
  

Their proposed strategic directions included the development and administration of a test of core prerequisite knowledge. Among the suggested action plans were the following two: (1) The TSDA is to decide the duration and content of each of the mandatory and desired categories of knowledge and skill. (2) There is to be increasing involvement of the thoracic surgery directors in the planning of general surgery rotations.

The impact of thoracic surgery and general surgery residencies on each other was considered by a group of 19 people led by Gordon F. Murray, who was the immediate past president of the TSDA. The historic and continuing relationship between these two specialities was appreciated, and considerable variability in this relationship from one institution to another was acknowledged. Among the proposed strategic directions was to increase the responsibility of thoracic surgery directors for the prerequisite curriculum. Among the suggested action plans were the following: (1) Mechanisms should be developed for identifying thoracic surgery residents at the earliest possible time in their education. (2) Thoracic surgery directors should undertake local and national negotiations toward assuming responsibility for the prerequisite curriculum. (3) Thoracic surgery directors should undertake negotiations with ABS that would permit or perhaps require the completion of ABS certification concomitant with the completion of prerequisite education. (4) Thoracic surgery directors should undertake negotiations with ABTS that would permit or perhaps require the completion of ABTS certification concomitant with the completion of required education in thoracic surgery. (5) Thoracic surgery and general surgery directors should together develop methods that would ensure residents with adequate time for leisure.

Subspecialty education within thoracic surgery residencies ("tracking") was considered by a group of 15 people led by William A. Baumgartner. There was consensus that the fundamental education for the subspecialties of cardiovascular surgery for adults, general thoracic surgery, and pediatric cardiac surgery should remain together. It was agreed that a generalized formal tracking system within the framework of existing programs is not advisable because such an effort could lead to fewer well-educated thoracic surgeons as compared with those currently being trained. The need for tracking in general thoracic surgery and in congenital heart surgery is already recognized, and such tracks are currently available as supplements to required thoracic surgery education. Among the proposed strategic directions was to determine in a detailed and formal way the education required for each of the three subspecialties of thoracic surgery. The suggested action plans included the following: (1) Measurement methods to assess the professional development of residents should be developed. (2) Criteria for integrated and coordinated pilot programs in thoracic surgery education should be generated.

American Board of Surgery certification was considered by a group of 19 people led by James L. Cox. The group members were all thoracic surgeons with special interest in cardiovascular surgery, except for a Canadian guest who heads a prestigious residency in general thoracic surgery. The proposed strategic directions included the following: (1) ABS certification should be optional as a prerequisite to thoracic surgery residency. (2) Thoracic surgery should seek ABS agreement to allow thoracic surgery residents to be eligible for the ABS examination and certification after 4 years of general surgery education. The suggested action plans included the following: (1) There should be negotiations with ABTS to offer examination of candidates with or without ABS certification. (2) There should be negotiations with the Residency Review Committee in Thoracic Surgery and ACGME to require each approved thoracic surgery residency to accept individuals with or without completion of an ACGME-approved residency. (3) There should be a TSDA advisory vote about the recommendation to make ABS certification optional. (4) The TSDA and ABTS should together negotiate with ABS regarding the matters discussed by this group.

The future of the TSDA in thoracic surgery was considered by 17 people led by Mark B. Orringer, the current president of the TSDA. It was agreed that mentors for residents need to serve as role models and that mentors should increase their recognition of residents as individuals with personal needs. The strategic directions proposed by the group were the following: (1) There should be emphasis on the work of the existing Curriculum Implementation Task Force, and on regular periodic updating of the existing curriculum for thoracic surgery residencies. (2) There should be greater resident participation and involvement in the affairs of the TSDA. The suggested action plans included the following: (1) The TSDA should support and encourage programs to provide residents with adequate time for study and leisure. (2) The TSDA should petition ABS so that thoracic surgery residents could complete their ABS examination within 4 months of completion of general surgery residencies. (3) The TSDA should add resident representation at least to its Curriculum Implementation Task Force and perhaps to its Executive Committee. (4) The TSDA should develop a standardized "exit interview" and assessment method. (5) The TSDA should hire a professional administrative staff.

The TSDA assessment of the Retreat and the resulting plan was developed by the Executive Committee and presented to the membership at its February 1997 meeting. It was recalled that virtually all leaders of thoracic surgery in the United States have been fully educated ABS-certified surgeons who chose to specialize further in thoracic surgery, and it was recognized that the ability thoracic surgeons have had to adapt, to be innovative, and to grow professionally can be attributed largely to the high quality of their total surgical education. Although the TSDA recognizes fiscal and political realities that have actual or potential impact on education, the drive to maintain excellence remains fundamental. The TSDA is convinced that the evolution of thoracic surgery education is to be based on educational considerations such as curriculum content and methods of curriculum implementation. Therefore, the TSDA favors the following positions and courses of action:

1. An "all payor" mechanism for funding graduate medical education is to be supported. Funding limitation based on the duration of postgraduate medical education is to be opposed.
   
2. Postgraduate education in thoracic surgery can begin upon graduation from medical school. Thus, the Program Directors of approved thoracic surgery residencies must be actively and continually involved in the planning and in the evaluation of the quality of the prerequisite education of thoracic surgery residents.
   
3. Programs that would integrate and better coordinate residencies in thoracic surgery and in general surgery, with mutual benefit to both specialities, need urgently to be developed and evaluated.
   
4. The thoracic surgery subspecialties of cardiovascular surgery for adults, general thoracic surgery, and pediatric cardiac surgery will remain together in a fundamental Thoracic Surgery Residency Program. Within the current structure of thoracic surgery residencies, tracking of residents into one of these subspecialties is not generally recommended.
   
5. The existing prerequisite requirement for ABS certification has served thoracic surgery education well; a better substitute does not now exist. The proposal to make ABS certification an optional prerequisite for thoracic surgery and simultaneously to make all thoracic surgery residencies 3 years long deserves serious attention. To consider this proposal properly, the TSDA is committed to working urgently toward improvement of prerequisite education for thoracic surgeons as determined by educational values. The TSDA will not give primary consideration to the time required for completion of prerequisite education or to ABS certification. Accordingly, the TSDA wishes actively to discuss with ABTS, ABS, and appropriate surgical educators the possibility of a better, more focused, and shorter prerequisite education for thoracic surgery residents.
   

	The Curriculum Implementation Task Force

Top Footnotes Introduction The Curriculum Implementation... TSDA Communication With Related... The Future References

 
The curriculum [3] is considered fundamental to the purpose of the TSDA. It was intended to be a living, growing document that deserves ongoing consideration of methods to implement its content, as well as continuing improvement of the content itself. A curriculum implementation task force chaired by Irving L. Kron was established and is currently working actively to assess and to improve methods of implementation. Among the most important aspects of its work is teaching and learning how to use modern information technology for the purpose of thoracic surgery education, including skills to be used in the operating room.

	TSDA Communication With Related Organizations

Top Footnotes Introduction The Curriculum Implementation... TSDA Communication With Related... The Future References

 
The Report of the Thoracic Surgery Directors Association Retreat, 1996 [4] was sent to The American Association for Thoracic Surgery, ABTS, The Coordinating Committee for Continuing Education in Thoracic Surgery, the Foundation for Research and Education in Thoracic Surgery, and The Society of Thoracic Surgeons. Each of these groups, in equal share with TSDA, had given financial support that made the Retreat possible; each group accepted the report and decided to leave residual funds from its grant with TSDA for the purpose of curriculum implementation and pursuit of the strategic directions that TSDA identified during the retreat.

The Association of Program Directors in Surgery invited the TSDA President to participate in its annual meeting in San Diego, April 2–5, 1997. The essence of the deliberations at the Retreat of 1996 was transmitted to the Association of Program Directors in Surgery Executive Committee and to its membership. The important sentiment within thoracic surgery in favor of making all residencies in thoracic surgery 3 years long and in favor of making it optional to have ABS certification before examination by ABTS was transmitted. The TSDA's ongoing work in curriculum planning and implementation was described to the Association of Program Directors in Surgery. The TSDA's plan to retain educational content and quality as the driving forces during change and adaptation was transmitted and well received. The need to teach and learn in the face of an ever-expanding knowledge base in thoracic surgery was discussed. Thoracic surgery's desire for prerequisite education that is more focused upon the needs of thoracic surgery, and the Thoracic Surgery Directors' strong desire to be more actively and earlier involved in the education of their residents was apparently well accepted by the Association of Program Directors in Surgery. The Executive Director of the ABS, Wallace P. Ritchie, Jr, participated in the discussions and expressed the viewpoint that the flexibility to provide the needs of thoracic surgery during general surgery education already exists within current ABS requirements.

	The Future

Top Footnotes Introduction The Curriculum Implementation... TSDA Communication With Related... The Future References

 
Mark B. Orringer became the President of TSDA May 3, 1997, for a 2-year term, and Gordon N. Olinger became the President-Elect. Thoracic surgery can be confident that they will provide outstanding leadership. However, the quality of the content of education in thoracic surgery will continue to be the fundamental insurance that our specialty will continue to be excellent in patient care, teaching, and research.

	Footnotes

Top Footnotes Introduction The Curriculum Implementation... TSDA Communication With Related... The Future References

 
Address reprint requests to Dr Benfield, Division of Cardiothoracic Surgery, University of California Davis Health System, Professional Bldg, 4301 X St, Sacramento, CA 95817-2214 (e-mail: john.benfield{at}ucdmc.ucdavis.edu).

	References

Top Footnotes Introduction The Curriculum Implementation... TSDA Communication With Related... The Future References

 

1. Gandhi S, Bromberg BI, Rodefeld MD, et al. Lateral tunnel suture line variation reduces atrial flutter after the modified Fontan operation. Ann Thorac Surg 1996;61:1299–309.[Abstract/Free Full Text]
2. Chen EP, Bittner HB, Davis RD, et al. The effects of nitric oxide after cardiac transplantation in the setting of recipient pulmonary hypertension. Ann Thorac Surg 1997;63:1546–55.[Medline]
3. Comprehensive Thoracic Surgery Curriculum. Published in 1995 by Thoracic Surgery Directors Association, Edward A. Verrier, Secretary TSDA, Division of Cardiothoracic Surgery, University of Washington, Box 356310, Seattle, WA 98195.
4. Report of Thoracic Surgery Directors Association Retreat, 1996. Published in 1997 by Thoracic Surgery Directors Association, Edward A. Verrier, Secretary TSDA, Division of Cardiothoracic Surgery, University of Washington, Box 356310, Seattle, WA 98195.

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