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Ann Thorac Surg 2001;72:1433-1437
© 2001 The Society of Thoracic Surgeons

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Report

"Change in the wind": report from the 2000 Thoracic Surgery Directors Association Retreat on Thoracic Surgery Graduate Medical Education

^a President, Thoracic Surgery Directors Association, USA

Address reprint requests to Dr Olinger, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226

	Introduction

Top Introduction Responses Options and conclusions Footnotes Acknowledgments References

 
In October, 1999, the American Board of Thoracic Surgery (ABTS) resolved that "the ABTS change current policy regarding American Board of Surgery (ABS) certification so that at a point in the future, yet to be determined, ABS certification will become optional." This position was taken by the ABTS after exhaustive study and debate of the relevant issues and of evolving data pertinent to Thoracic Surgery Graduate Medical Education (TSGME), a topic of three major conferences in the last decade¹ and of the addresses of seven thoracic societal presidents, four of them in the last 6 years. Among the most provocative points that were considered by the Board were: (1) The vast expansion of fundamental knowledge and of operative approaches to cardiothoracic diseases currently required to educate the TS resident in a time-frame essentially unchanged since formal education in TS began in 1928; (2) a total duration of medical school and of GME that obligates the thoracic surgeon entering practice to be older, as compared to peers in other professions, and to be constrained by greater indebtedness; (3) a disturbingly diminished pool of applicants to TS residencies, with fewer US medical graduates applying than residency positions to fill; and (4) diminishing funding for TSGME occurring concomitantly with increasing financial burdens on academic thoracic surgery programs. The specific intent of the ABTS was to facilitate change if change were to be the desire of thoracic surgery educators and of the other parties in organized thoracic surgery vested with interest in, and responsibility for, the process and product of TSGME.

These interested parties embody the Joint Council on Thoracic Surgery Education (JCTSE), which was founded in 1997.² The JCTSE responded to the action of the ABTS with a straw man proposal for change to be considered by each parent of the JCTSE. That proposal reads:

1. To develop programs that stimulate the interest of students in cardiothoracic surgery while they are in medical school as well as during the surgical core experience so that they will be more likely to enter the specialty. Further, to work toward making cardiothoracic residencies more user-friendly, in terms of less service requirements and more educational opportunities, and finally to work toward encouraging women to enter the field of cardiothoracic surgery.
   
2. To agree that for the education of a cardiothoracic surgeon, a minimum residency program in a range of 6 years would be appropriate and would consist of a categorical surgical core of 3 years followed by a cardiothoracic residency of 3 years, with a match to take place in the midportion of the categorical PGY3.
   
3. To accept, as a tentative list, those curricular components as follows: Prerequisites: Critical care, trauma, nutrition, infectious disease, transfusion medicine, surgical oncology, communication skills, information technology, radiology/imaging, plastic surgery, endoscopy, pediatric surgery, geriatrics, ENT, transplantation, immunology, vascular surgery, GI surgery, cardiac surgery, thoracic surgery, and various electives. Requisites: Echocardiography, catheterization laboratory, vascular biology, general thoracic surgery, oncology, interventional radiology, imaging, pulmonary medicine, GI medicine, perfusion technology, adult cardiac surgery, pediatric cardiac surgery, and various electives.
   
4. To recommend that all cardiothoracic education programs should be flexible to provide greater exposure in nonsurgical fields and those fields of particular interest to the residents.
   
5. To recommend that the foundation of cardiothoracic surgery be defined by thoracic surgeons who must participate in the educational process.
   
6. To accept the concept that certification by the American Board of Surgery may not be essential, and to propose the restructuring of the curriculum necessary to train highly qualified cardiothoracic surgeons.
   
7. To continue to discuss these proposals with the constituencies of the representatives of the Joint Council to identify problem areas, and to bring such issues to the Joint Council at a meeting within 6 months.
   

The Thoracic Surgery Directors Association (TSDA) met in retreat in September 2000 in Chicago, Illinois, in reaction to the proposal of the ABTS and with the explicit goal to provide critical feedback to the JCTSE. This report summarizes those deliberations and their implications.

The retreat was designed to engender informed discussion about TSGME with respect to its current and possible future content and construct. Substantive background information on TSGME was provided through plenary lectures and a binder of selected publications and data sent to participants in advance.

Introductory material in a plenary session addressing the resolution of the ABTS and the straw man proposal of the JCTSE was provided by Fred A. Crawford, Jr, MD, current chairman of both organizations. David L. Larson, MD, representing the Plastic Surgery Program Directors and the American Board of Plastic Surgery, provided an overview of current GME in Plastic Surgery. He discussed both the integrated and independent residency programs, and outlined the core prerequisite and requisite curricula on which the integrated programs have evolved and are currently based. He also described the Core Examination for the prerequisite curriculum, which was ß-tested shortly after the TSDA Retreat. Paul Friedmann, MD, then Chairman of the Accreditation Council for GME (ACGME), discussed the position of the ACGME with respect to outcomes assessment in GME, and provided the broad perspective of the ACGME toward the concept of core prerequisite education.

Electronic polling of the attendees was performed at the end of the plenary session and again at the end of the retreat.³ Tallies were taken in response to a set of key questions drafted by the Program Committee and to the seven separate positions of the straw man proposal of the JCTSE. Individuals were permitted one of four responses for each question or statement: strongly agree, agree, disagree, or strongly disagree. Tallies of demographic information permitted correlation of item responses with selected groupings among the attendees.⁴

Six break-out groups were constituted by random assignment of enrollees. Each group had two group leaders selected by the Program Committee to provide broad representation among the three subspecialty disciplines within Thoracic Surgery (adult cardiac, general thoracic, and pediatric cardiac). The first break-out was allowed to be free-wheeling, to permit participants freedom of expression, to engender creative ideas, and to allow a certain amount of "letting off of steam." The second break-out specifically addressed the concept of a restructured TSGME occurring in a more ideal world free of current constraints. This session brought the retreat to bear on the straw man proposal of the JCTSE. Group leaders facilitated focused discussions of a 3-year requisite TS residency preceded by a 3-year prerequisite, either in the form of a core common to all specialties including General Surgery, or in a foreshortened general surgical exposure. Each group also discussed an integrated 6-year program with matching to TS out of medical school. The last break-out examined each of the key consensus questions. The final list of questions for polling mirrored the first list but embodied clarification of definitions and of language (Table 1).

	Responses

Top Introduction Responses Options and conclusions Footnotes Acknowledgments References

 
Summary statements of discussions that occurred in break-out were provided by group leaders. Although there were widely disparate opinions expressed throughout the Retreat on some issues, ultimately there was remarkable agreement on most. With respect to the first two consensus questions, 95% of participants agreed that "TSGME can be improved through restructuring the curriculum." Similarly, 96% agreed that "we should change prerequisite and requisite curriculum to improve TSGME," with representative distribution of agreement across surgical practice. These two questions and the responses to them set the philosophical stage for subsequent responses.

Responses to the questions relative to the best approach to TSGME in today’s world and in the ideal world. "Today’s world" was defined as our current environment in which our relationships with the ABS (the process and timing of examination) and with other specialties are unchanged. The "ideal world" was defined as that in which relationships were altered such that constraints on such changes as a common prerequisite core for all surgical specialties were eliminated. In both circumstances, ABS certification to qualify for ABTS certification was assumed to be optional. For today’s world, 41% of the respondents were willing to stick with the present system, whereas 43% favored foreshortening GS; 16% opted to pursue an integrated approach with matching out of medical school. For the ideal world, a minority (14%) stuck with the present system. The core concept drew 41%, whereas respondents for the integrated program increased to 27% and respondents for shortened GS increased to 18%. The question regarding duration of TSGME (ie, should our prerequisite education remain the same) drew quite different responses pre- and postdiscussion, with the postdiscussion vote clearly favoring continued flexibility (62%) for either 2 or 3 years of TSGME as is current practice. Contrarily, there was overwhelming support (83%) for 3 years as the optimal duration for TSGME.

When it came to deciding upon implementation of change—if it is to occur—most respondents desired either gradual change if it were to be mandatory, or (preferably) voluntary participation. Almost everyone (92%) agreed that changes needed careful oversight and ongoing evaluation through an independent task force. In considering the timing of the specialty match into TS in the ideal world, opinion was split between matching in medical school (those favoring the integrated approach) and later in the idealized prerequisite (3rd or 4th year, depending on length).

There was no vacillation of opinion pre- versus postdiscussion regarding the merits of ABS certification for ABTS qualification, with 57% favoring optional ABS certification and 43% preferring that it be kept mandatory. Only in the subset of individuals practicing both adult cardiac and general thoracic surgery did there appear to be a preponderance of opinion favoring retention of mandatory ABS certification (Fig 1). Finally, the question was asked whether "if the GS programs do not go to a core curriculum system, would you still favor a 3/4-year core prerequisite program for TS residents?" A total of 62% of respondents favored the core concept (even in this more limited setting), a slight increase from 58% prediscussion.

View larger version (34K): [in this window] [in a new window]   Fig 1. Thoracic Surgery Directors Association Residency Program Retreat, September 2000. Response to the consensus question: "If the present system remains the same, the American Board of Surgery certification should be __________________." Analysis is by the type of surgical practice of the respondent. (A Card = adult cardiac; AC-CC = adult cardiac-congenital cardiac; AC-GT = adult cardiac-general thoracic; ALL = All (A card, C Card, G Thor); C Card = congenital cardiac; G Thor = general thoracic.)

	Options and conclusions

Top Introduction Responses Options and conclusions Footnotes Acknowledgments References

The options to bring about change in TSGME can be grouped into four broad categories, each of which was discussed during the Retreat.

"Smithing" the current system
Three fairly discrete possible changes have been discussed in the past and remain topical today. These are expansion of TS exposure during the minimum 5-year GS prerequisite, expansion to 3 years of requisite TS residency for all programs, and restructuring of the ABS qualifying examination to have it occur during the 5th year of general surgery. While each of these items individually has merit, the discussion about them has been ongoing for years with little substantive change. It is apparent that none of these changes individually or as a group would address many of the fundamental concerns that have been raised about the prerequisite to TSGME.

Foreshortened GS prerequisite with expansion of TSGME to 3 years
This model assumes that a categorical GS resident would choose TS at some time during the first 3 to 4 years. For practical purposes, only a late decision would allow such a resident to remain in good standing as a more senior resident in GS. Cooperation of the GS and TS program directors in any such program would be essential for meritorious design of prerequisite rotations and provision of "senior experience" for the would-be TS resident.

Integrated TSGME
This type of program follows the model established by the educators in Plastic Surgery. TS Residents would be matched out of medical school. From day 1, curricular structure and control allegedly would be in the hands of the TS Program Director for assignment of rotations, quality of non-TS content, and evaluation of performance.

The very successful integrated program at Johns Hopkins Medical Institutions, now abandoned, qualified residents for examination by both the ABS and ABTS.

Core prerequisite curriculum
This concept in its fully fleshed-out form would establish a curricular structure and content common to each of the subscribing specialties that have traditionally stemmed from the "mother" Surgery. General Surgery in this context would be such a specialty. The idea is not new, having been posited with some modifications for Surgery in the past by surgical educators, Robert Barnes, MD [1,2] and Walter Pories, MD [3]. This model was actually incorporated into the straw man Proposal from the JCTSE. It has been discussed in the Council at great length and has been offered for discussion as a very credible option in an ideal world. In this model, all residents in the common core remain categorical surgeons until a specialty match, probably within the 3rd of 3 years. Electives within the core permit testing of waters in the specialties, but core knowledge and basic skills are the subject of a fundamental curriculum common to all residents.

Establishing a standard for prerequisite performance and acquisition of knowledge is essential if ABS certification—the current standard—becomes optimal. The Plastic Surgery core examination has been created with assistance of the National Board of Medical Examiners to try to establish a "bar height" for fundamental knowledge that all candidates for certification by the ABPS must acquire whether they come from traditional, so-called independent programs, from the newer integrated programs, or from other disciplines (such as Otolaryngology) and already Boarded in that specialty. The implementation of their core examination is still in its early phases. It is an important precedent that must be observed carefully by TS educators if they are to restructure the prerequisite curriculum.

Development of such a common core for the broader group of surgical specialties is certainly not forthcoming in the foreseeable future. Nevertheless, there is merit in continuing the dialogue among surgical educators to evaluate the place for this type of prerequisite as a desirable long-term goal.

The debate over these models culminated in a clear, decisive consensus among TSDA retreat participants that the following concepts should be embodied in the future of TSGME: (1) Restructuring of prerequisite TSGME is imperative to focus on fundamental content, to reduce wasted or misdirected time, and to emphasize education relative to service. (2) A categorical core prerequisite with a delayed match common to the relevant surgical specialties including general surgery would be most effective to meet prerequisite needs in the long term but is impractical in the short term. (3) ABS certification may not be essential to achieve the desired improvement in TSGME. (4) If the prerequisite can be restructured satisfactorily, requisite TSGME should be increased across the board to approximately 3 years. (5) Expanded requisite education should provide flexibility and increased options for tracking into the subspecialties. (6) Implementation of change should be gradual and, at the outset, should be administered by those programs willing and able to do so, and (7) The process and product of change must be overseen prospectively by an organized body.

Follow-up
On February 11–12, 2001, the JCTSE met to deliberate the next steps toward modification of TSGME. The affirmation by the TSDA of the JCTSE’s straw man proposal facilitated a very constructive discussion that resulted in the JCTSE recommending the following:

1. That the JCTSE support the proposal by the ABTS that ABS certification become optional for ABTS certification;
   
2. that prerequisite curriculum be of no less than 3 years duration;
   
3. That total prerequisite and requisite curriculum be of no less than 6 years duration;
   
4. That the ABTS and the Thoracic Surgery RRC facilitate the opportunity for increased flexibility in requisite education to take into consideration the individual TS resident’s desire to concentrate in a Thoracic Surgery Subspecialty and the capabilities of individual programs to provide creative flexibility; and
   
5. That the TSDA be charged with developing minimal prerequisite requirements in the absence of ABS certification for entry into the certifying process of the ABTS.
   

A TSDA work group on prerequisite requirements was created and will report its recommendations to the JCTSE by June 1, 2001. Subsequent steps to implementation will necessarily include the drafting and final approval by the ABTS of new minimal prerequisite and requisite requirements for ABTS certification, and the drafting and final approval by the Thoracic Surgery RRC of new special requirements for programs that might be mandated by changes in length of training, in content, and in flexibility of training. Substantive changes in the process of certification of surgeons by the ABTS will have to be approved by the American Board of Medical Specialties. Substantive changes in specialty requirements of the RRC will have to be approved by the ACGME.

Finally, a mechanism for long-term evaluation must be designed, implemented, and funded to test the outcomes and validity of new curricular structures. The TSDA is highly committed through a new standing committee on Curricular Evaluation to integrate this function into its ongoing activities as the organization singularly dedicated to the education of TS residents. It is expected that a request for proposals will be submitted to program directors to develop pilot programs that will fit within the new guidelines of the RRC and ABTS, and that each of these programs would be approved individually by a body as yet to be constituted but most likely to be derived from the JCTSE and the TSDA

	Acknowledgments

Top Introduction Responses Options and conclusions Footnotes Acknowledgments References

 
I am grateful to the members of the TSDA Executive Committee and to Fred Crawford, Jr, MD, for their contributions to the content and conclusions of this manuscript.

	Footnotes

Top Introduction Responses Options and conclusions Footnotes Acknowledgments References

 
¹ Planning Session of the American Association for Thoracic Surgery, September 1991, Snowbird, Utah; Joint Conference on Graduate Education in Thoracic Surgery, September 1992, Oak Brook, Illinois; "Directions in Thoracic Surgical Education," Retreat of the Thoracic Surgery Directors Association, October 1996, Chicago, Illinois.

² The JCTSE is constituted by two representatives each from the Thoracic Surgery Directors Association, The Society of Thoracic Surgeons, the American Association for Thoracic Surgery, the American College of Surgeons Advisory Council on Cardiothoracic Surgery, the Thoracic Surgery Residency Review Committee, and the American Board of Thoracic Surgery.

³ Electronic balloting provided through an educational grant from Merck, Sharpe & Dohme, Inc.

⁴ Complete demographic information along with responses to key questions are available on the TSDA Website, www.tsda.org/doc/4922.

	References

Top Introduction Responses Options and conclusions Footnotes Acknowledgments References

 

1. Barnes R.W. Moving general surgery into the 21st century: blueprint for change. Curr Surg 1993;50:667-669.
2. Barnes R.W. Management of future changes for graduate surgical education: the challenges for academia. Curr Surg 1995;52:446-453.
3. Pories W.J. Some reflections on Halsted and residency training. Curr Surg 1999;56:1.

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