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Ann Thorac Surg 2000;69:1321-1326
© 2000 The Society of Thoracic Surgeons
a Department of Surgery, Northwestern University Medical School, Chicago, Illinois, USA
b Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia, USA
c Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia, USA
d University of Michigan, Ann Arbor, Michigan, USA
Address reprint requests to Dr DaRosa, Department of Surgery, Northwestern University Medical School, 250 E. Superior, Suite 201, Chicago, IL 60611
e-mail: ddarosa{at}nmh.org
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Abstract |
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Methods. Graduates of multiple TSDA programs were mailed a 50-item questionnaire. Survey items were objectives from the TSDA curriculum book representing six areas of thoracic surgery. Graduates rated each objective for adequacy of instruction and relevance to their current practice on Likert-type scales.
Results. Two hundred twenty-eight surveys were included in the analysis. Despite excellent operating room education, graduates across subspecialty lines reported the need for improved education in "nonoperative" subjects. Graduates practicing cardiac surgery reported little relevance of their general thoracic educational experience. Conversely, graduates practicing general thoracic surgery expressed the need for more/better educational experiences in thoracic oncology and esophageal surgery.
Conclusions. Contemporary thoracic surgical education can be improved. A strong need for improvement exists in the teaching of "nonoperative" subjects. As graduates elect careers in thoracic subspecialties, a need exists to align thoracic surgery educational experiences with ultimate career goals of residents.
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Introduction |
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The Thoracic Comprehensive Curriculum reflects the opinion of the thoracic surgery educators as to what constitutes important content for residency education programs, ie, the "teachers’ view of what the students should learn." The relevance of the curriculum, however, to current thoracic surgical practice from the perspective of recent residency graduates has not been assessed. The curriculum evaluation study described here was accomplished through feedback from recent graduates of American Council of Graduate Medical Education (ACGME)-approved thoracic surgery residency programs. More specifically, the study addressed the following questions:
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Material and methods |
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Instrument
A survey was drafted listing 101 selected objectives from the Thoracic Comprehensive Curriculum Document. Objectives were selected for inclusion in the survey by one CITF member and reviewed for consensus by other members. Because of the high number of objectives selected, items were randomly split by category into two survey forms referred to as Form A and Form B. Table 1 shows the breakdown of items by category for both forms reflecting their equivalence.
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CITF members reviewed the survey and cover letter for content balance and clarity of instructions and scales. The cover letter explained the importance of the study, requested a 2-week return, assured anonymity of respondents, and listed phone numbers of people to call if they had questions. The CITF member’s signature appeared on the cover letter for surveys sent to their respective graduates.
Surveys were distributed enclosing a self-addressed stamped envelope. A few days after the requested return date specified in the cover letter, a second mailing was sent to nonrespondents with a new follow-up letter, copy of the survey, and self-addressed stamped envelope.
Data analysis
Data were analyzed using descriptive statistics. Mann-Whitney U analysis was completed to study differences in responses based on participants’ years in practice, practice types, and settings. Differences were considered significant at the p = 0.05 level.
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Results |
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Of the 225 reporting their practice setting type, 59% indicated they were in private practice and 41% reported being in an academic setting. The average "type of practice" profile (n = 226) reflected practices with 10% pediatric cardiac, 65% adult cardiac, and 25% general thoracic patients. The number of years in practice (n = 226) were reported as follows: 1 year or less, 60 (26%); 2 years, 52 (23%); 3 years, 52 (23%); 4 years, 40 (18%); and 5 or more years, 22 (10%). Respondents’ responses to these demographic questions on both survey forms were very similar.
A rank list of least relevant objectives from Forms A and B is shown in Table 2. The 31 objectives included in the table received mean ratings from 1.73 to 2.50 on the four-point scale. The means of these items on Form A ranged from 1.83 to 2.50 and the median for all of these items was 2. The means on the least relevant ranking list on Form B ranged from 1.73 to 2.47. The median for items B6, B22, and B25 was 1 and for the remainder it was 2.
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With respect to the adequacy of instruction, respondents from an academic setting significantly differed from their private practice counterparts in their perceptions of the adequacy of experience/instruction in several areas. Academic-type respondents thought that two objectives (one from Form A; one from Form B) received too little experience/instruction (manage ventilators for infants and children with and without obligatory intracardiac shunts; know the indications for and operative repair on congenital diaphragmatic hernia). Academic-type respondents reported two objectives (both from Form B) as being given too much experience/instruction in contrast to ratings received from private practice-type respondents (evaluate and diagnose neoplasia of the lung, using knowledge of the histologic appearance of the major types; understand the etiologic process, presentation, and management of acquired tracheal strictures and their prevention).
Several differences existed in responses based on the respondents’ type of practice. For this analysis, respondents who noted that their practice was 0% to 49% general thoracic were classified as "predominantly cardiac." Those who indicated 51% or more of their patients were general thoracic were classified as "predominantly general thoracic." Those describing their practices as 50% general thoracic and 50% cardiac were excluded from this part of the analysis.
Twenty-nine objectives from Forms A and B were considered significantly more relevant by the Cardiac Group (n = 192) versus the General Thoracic Group (n = 26). Fourteen of these objectives were from the AHD category and ten were in the CHD category. The Cardiac Group rated 46 objectives as less relevant to their practices with 38 of these objectives coming from the general thoracic category, 5 from the TT category, and 3 from the T category.
Perceptions of adequacy of instruction also differed significantly in several areas between the Cardiac and General Thoracic Groups. Cardiac surgeons reported that the adequacy of instruction was significantly less for the objective "perform operative and nonoperative management of patients with ischemic heart disease, including coronary bypass grafting using the internal mammary artery." The General Thoracic Group rated nine objectives as being less adequately taught or experienced during residency. Examples of these included understand the methods of invasive staging of lung cancer; understand the causes, physiology, evaluation, and management of hemoptysis; read and interpret pulmonary function studies, ABGs, and pulmonary arteriograms and correlate results with operability for lung resections; and interpret manometric and pH studies of the esophagus. Two others fell into the extracorporeal bypass and coagulation-blood products (EBCBP) category and the remainder in the GT category.
Participants who completed Form A who had been in practice less than 5 years did not significantly differ in their perceptions of the relevancy of the objectives from those with 5 or more years of practice experience. They did, however, rate the item "evaluate transplant recipients for signs of rejection or infection, and initiate appropriate therapy" significantly higher on the adequacy scale (more toward the "too little instruction" end of the scale) than those who had been in practice for 5 years or longer. On Form B, respondents in practice less than 5 years did differ from those with 5 or more years of practice experience on the relevance of three objectives in the AHD category, considering them significantly lower in relevance. Conversely, they rated one objective (manage the lung transplant recipient preoperatively and postoperatively) significantly higher in relevance than the 5 or more years group. Respondents in practice less than 5 years rated three objectives (understand the types of cardiac tumors; manage cardiac transplant recipient preoperatively and postoperatively; know the indications for and operative repair of congenital diaphragmatic hernia) significantly higher on the adequacy scale (more toward the "too little" end of the scale) than those with at least 5 years in practice.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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These results suggest that despite excellent operating room education, graduates across subspecialty lines see a need for improved education in "nonoperative" subjects such as echocardiography, nuclear cardiology, esophageal motility studies, and oncology protocols. Graduates practicing cardiac surgery reported little relevance of their general thoracic educational experience. Conversely, graduates practicing general thoracic surgery reported far too much emphasis in their residencies in cardiac surgery and expressed the need for more/better educational experiences in thoracic oncology and esophageal surgery. Table 4 shows that tracheal surgery is inadequately addressed in the curriculum (7 of 21 objectives), so it seems appropriate to offer special attention to it in spite of the "low to moderate" relevance ratings reflected in Table 2. Special emphasis on hypertrophic cardiomyopathy and mediastinal neoplasms also might be appropriate.
In general it appears that responders did think that some objectives were more relevant than others, although ratings on the adequacy of instruction did not vary substantially. Most graduates believed that the objectives were sufficiently taught/learned as the mode for the majority of the items was 2. Not surprisingly, for the objectives rated least relevant, six were rated in the "too much" end of the scale for adequacy of instruction. Interestingly, three objectives were among the least relevant items and the "too little" adequacy of instruction items. Similarly, five objectives (A12, A38, B22, B25, and B38) were among the most relevant items and also among the "too much" adequacy items. Two objectives (describe outcomes of angioplasty and of operative and nonoperative treatment of coronary artery disease, using statistical methods; interpret intraoperative echocardiograms for valve repair and replacement) were considered highly relevant and in need of additional emphasis or instruction. Videotapes, audiocassettes, computer-assisted instruction, distance learning programs, self-instructional modules, or other teaching/learning modalities could be designed to supplement current instruction in these two areas to ensure appropriate access for residents. Thirty-one objectives were not considered relevant to graduates’ practices. The majority of these fell into the CHD and T categories.
The results of this study raise the question as to whether thoracic residency programs should continue providing as much of a solid broad-based education as possible, or one tailored to the resident’s anticipated career goals and learning needs. For example, respondents who were largely cardiac surgeons suggested more/better instruction was needed in areas such as cardiac echocardiography, complications of myocardial infarction, and cardiopulmonary bypass. General thoracic surgeons suggested that additional emphasis be given on topics such as pericardial diseases, operability as relates to lung resections, and risk/benefit operability as relates to aortic aneurysms.
With time constraints of thoracic residents and faculty members caused by increased service demands, faculty need to ensure that trainees are efficiently exposed to the scope and emphasis on topics or skills that will be needed once they progress to independent practice. The development of the Thoracic Surgery Curriculum objectives is a step forward as the document offers guidance to program directors and residents as to what should be learned before graduation. It serves as a guide to planning and sequencing conference topics, assigning patients, and determining questions important for residents to know. It is key, however, that the link purposely exists between the knowledge and skill areas outlined in the learning objectives and the experiences and instruction provided during the residency program. Although much of the patient experiences a resident receives has to do with patient availability, geography of the program, and number of residents competing for patients, faculty need to ensure through regular progress reviews that each learner is receiving an adequately balanced array of learning activities and experiences.
Curriculum evaluation studies such as the one described here are critical to determining the validity of curriculum content to future practice. Researchers considering the use of this or a similar instrument should employ a larger "adequacy of instruction/experience" scale given the restricted range of responses yielded in this study. Although these findings suggest that many objectives are being addressed adequately during the residency program term, longitudinal follow-up studies such as this should continue to be done on a scheduled basis to monitor whether the intended curriculum is correlated sufficiently to actual practice needs.
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